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* 



ESSENTIALS 



OF 



■ 



SURGERY. 



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SAUNDERS' QUESTION-COMPENDS. No. 2. 

ESSENTIALS OF SURGERY, 



TOGETHER WITH A 



FULL DESCRIPTION OF THE HANDKERCHIEF 
AND ROLLER BANDAGE. 



ARRANGED IN THE FORM OF 



QUESTIONS AND ANSWERS 

PREPARED ESPECIALLY FOR 

STUDENTS OF MEDICINE. 



BY 
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CLINICAL PROFESSOR OF GENITO-URINARY DISEASES IN THE UNIVERSITY 
OF PENNSYLVANIA. 



ILLUSTRATED. 



Seventh Edition, Revised and Enlarged 

WITH AN APPENDIX 

CONTAINING 

FULL DIRECTIONS AND PRESCRIPTIONS FOR THE PREPARATION OF 

THE VARIOUS MATERIALS USED IN ANTISEPTIC SURGERY. 

ALSO SEVERAL HUNDRED RECEIPTS COVERING THE MEDICAL 

TREATMENT OF SURGICAL AFFECTIONS. 



PHILADELPHIA : 

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925 Walnut Street. 

1900. 






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PREFACE TO THE SEVENTH EDITION. 



The fact that new editions of this little book continue to 
be called for from time to time justifies the author in feeling 
that his efforts to provide the student with a satisfactory 
groundwork for the study of surgery have not been altogether 
in vain. 

He has taken pleasure, therefore, in subjecting the volume 
to a careful and thorough revision, in order that it might 
represent, as fully as is possible in a work of the kind, the 
present status of surgical theory and practice. 

Numerous changes and additions have been made through- 
out the text ; and it seemed advisable to add a section on the 
modern treatment of appendicitis. 



IX 



PREFACE TO FIRST EDITION. 



As one thrown yearly in contact with large numbers of 
medical students, and familiar with the furious rate at which 
they are driven, the writer feels assured that, under our 
present system of rapid education, outline works are of dis- 
tinct value. Third year men who attend six lectures and 
two clinics daily have no time for reading, no time for sys- 
tematizing their knowledge on any one subject. This work 
must either be done for them, or left undone. The author 
has carefully gone over the subject of Surgery, and has en- 
deavored to emphasize the essential points as a framework 
upon which more detailed knowledge may be hung. Agnew, 
Ashhurst, Gross, Walsham, Tillmann, Kbnig, Treves, Weir, 
Smith, Gerster, and many others have been freely consulted. 
The table of Urinary Calculi is taken direct from Moullin's 
article in Treves's manual. The classification of Venereal 
Diseases follows that of White (University of Pennsylvania). 
To Mr. W. M. Alrich and Mr. Daniel Webster thanks are 
due for their valuable assistance. 

The author has made an earnest effort to be accurate, 
concise, and modern. 

E. M. 



CONTENTS. 



, PAOB 

Inflammation 17 

Abscess ' 27 

Ulceration ' 31 

Mortification u ......... 38 

Wounds ~ 44 

The germ theory of 44 

Shock r -45 

Wound fever l ' 47 

Erysipelas 50 

Tetanus 52 

Hydrophobia "" 54 

Glanders . . . . . . * . . .55 

Malignant pustule 55 

The healing of wounds 56 

The treatment of wounds 57 

Wounds of arteries 73 

Wounds of nerves 75 

Head injuries 76 

Injuries of the meninges and brain .... 81 

Concussion and contusion "". 83 

Compression 84 

Intracranial inflammation 85 

Cerebral localization . 87 

Wounds of the face 90 

Wounds of the neck 91 

Wounds of the chest 92 

Wounds of the abdomen 0-*i 

Burns and scalds ll)2 

xiii 



xiv CONTENTS. 

PAGE 

Fractures 105 

Special fractures .""" 112 

Luxations or dislocations 137 

Special luxations 140 

Sprains . . 158 

Wounds of joints 159 

Synovitis 160 

Arthritis 161 

Coxalgia 163 

Sacro-iliac disease 166 

White swelling of the knee-joint 166 

Rheumatoid arthritis . ....... 167 

Loose bodies in joints 167 

Anchylosis 168 

Diseases of bones ' . . . . . . 169 

Periostitis ■ . 169 

Osteitis .... .... 170 

Osteomyelitis 170 

Abscess of bone 171 

Caries 172 

Necrosis 172 

Tubercle 173 

Syphilitic bone disease 173 

Osteomalacia «* 174 

Pott's disease 174 

Rickets 176 

Haemophilia 177 

Struma 177 

Curvature of the spine ...... 177 

Hernia . 179 

Special hernias 188 

Appendicitis . . . 195 

Intestinal obstruction 198 

Diseases of the anus and rectum . . . • . . 200 

Syphilis 208 

Chancroid ■ . . .212 

Gonorrhoea 213 

Urethral deformities 219 



CONTENTS 



xv 



PAGE 

Stricture of the urethra 219 

Diseases of the prostate 226 

Affections of the bladder 229 

Rupture of the bladder . 229 

Exstrophy of the bladder . . . . .229 

Cystitis . 230 

Atony and paralysis of the bladder ■ , . . . 231 

Hematuria 231 

Retention of urine 232 

Stone in the bladder 235 

Hydrocele 240 

Hematocele 241 

Varicocele 242 

Sarcocele . 242 

Diseases of veins 244 

Angeioma 246 

Aneurism 247 

Diseases of the lymphatics . '— 250 

Effects of cold . . . 251 

Foreign body in the air-passages 252 

Affections of the oesophagus ...... 253 

Surgical affections of the breast 255 

Club-foot 256 

Hare-lip and cleft palate 257 

Diseases of bursa? and tendons 258 

Bursitis - 258 

Onychia . 259 

Anaesthetics 260 

Ligation of arteries 263 

Excision of joints ........ 280 

Amputations . . . * .... 284 

Tumors 292 

Bandaging . . . 296 

The roller bandage 296 

Head bandage ........ 305 

Handkerchiefs . . . . . . . .307 

The Rontgen ravs . 315 



ESSENTIALS OF SURGERY. 



si 



INFLAMMATION. 

What is inflammation ? 

Inflammation is the succession of changes which occurs in 
an injured living tissue, provided the injury is not to the degree 
of at once destroying tissue or vitality. 
Name the varieties of inflammation. 

Acute and chronic, simple and infective. 
What is simple inflammation ? 

An inflammation limited in extent, and tending to recovery. 
What is infective inflammation ? 

An inflammation caused by micro-organisms, and having a 
tendency to spread. 
What is coagulation necrosis ? 

Death of tissue from arrested nutrition or from the action 
of chemical or thermal agents, the changes seen being due 
partly to coagulation of lymph, and partly to cell changes. 

Name the causes of inflammation. 

1. Predisposing. Anything lowering the powers of resistance, 
sueh as heredity, age, sex, occupation, habits, food, previous in- 
flammation, temperature, climate, temperament, mental con- 
dition. 

2. Exciting. Traumatism, heat, cold, acids, alkalies, micro- 
organisms and their products. 

How does inflammation extend? 

By the means of bloodvessels or lymphatics. Extension by 
continuity, contiguity, metastasis, and sympathy is really due to 
either the blood or lymph vessels. 

How may inflammation terminate ? 

1. Kesolution, or return of tissues to their normal condition. 

2. Organization, or tissue-production. 

3. Death of tissue, by suppuration or mortification. 

What are the phenomena of inflammation ? 

1. Disturbed innervation, causing, first, a contraction of the 
2 



18 ESSENTIALS OF SURGERY. 

capillaries, followed shortly by a paralytic dilatation producing 
active hyperemia. 

2. Alteration in the bloodvessels and contents. The vascular walls 
are widely dilated, plastic, and their endothelial cells greatly 
swollen. The white blood corpuscles are numerous, cling to the 
sides, and the current is slowed or stopped. The red corpuscles 
stick together ; the liquor sanguinis contains more fibrin forming 
elements. 

3. Exudation or passage through the walls of white corpuscles 
(diapedesis) and liquor sanguinis. 

4. Alteration in the perivascular tissue. Intercellular matrix 
undergoes mucoid softening, connective-tissue corpuscle white 
blood-cells proliferate, the exudate coagulates. 

What zones are found about an inflamed area ? 

Most peripherally, a bright red ring where the bloodvessels 
are widened, called the zone of determination. Within this an 
area in which from overcrowding the blood current is slow, the 
color here is somewhat dusky, this area is called the zone of 
congestion. Centrally, an area where the blood current is prac- 
tically at a stand-still, this is the focus of inflammation, and is 
termed the zone of stasis. 
What are the stages of inflammation? 

First stage. Acute hypercemia with slight exudation. 

Second stage. Lymphatization or free exudation and the for- 
mation of plastic lymph. 

Third stage. Suppuration or formation of pus due to the death 
of white blood corpuscles and their fibrinous trabecule. 
What is plastic lymph? 

The exudate of acute inflammation. It is made up of white 
blood corpuscles and proliferated connective-tissue cells, im- 
bedded in a frame-work of coagulated fibrin. It is also called 
embryonic tissue. 
Name the different kinds of exudate. 

1. Serous. Thin, non-organizable. Examples : hydrocele, 
ascites, hydrothorax. 

2. Fibrinous. Contains much fibrin, coagulates, and readily 
undergoes organization, 



INFLAMMATION. 19 

How may the various stages of inflammation terminate? 

Active hyperemia may terminate in resolution or in exudation. 

Exudation may terminate in resolution, organization, or sup- 
puration. 

Suppuration may terminate in ulceration or death of the 
part. 

Describe resolution. 

The dilated vessels again contract, the white blood corpuscles 
begin to move away from the inflamed area as circulation is 
restored. The migrated corpuscles either return to the blood- 
vessels, degenerate, and are carried off by the lymphatics, or 
remain as fixed connective-tissue corpuscles. The fibrin becomes 
granular and is absorbed. 

Describe organization. 

New bloodvessels are formed in the exudate by looping of 
the old ones ; these loops anastomose with each other, forming 
a network. In addition new vessels are separately developed 
in the inflammatory tissue which, in turn, anastomose with the 
previously existing vessels. If the irritation ceases many of the 
exudation cells disintegrate and are removed, others are con- 
verted into connective-tissue corpuscles, which, by their contrac- 
tion, obliterate the new bloodvessels and form cicatrices. 

Describe suppuration. 

Pyogenic cocci are introduced, and they liquefy the exudate 
by the action of their ptomaines, and so form pus. 

What is phagocytosis ? 

The process in which white blood-cells attack, devour, and 
destroy invading organisms. 

What is pus ? 

Pus is the product of suppuration. It is a creamy-looking, 
highly albuminous liquid, sp. gr. 1030, and contains fat, blood 
salts, tyrosin, leucin, and other nitrogenous derivatives, pyogenic 
organisms and their ptomaines. On standing it separates into 
liquor pur is, a clear liquid, practically the same as liquor san- 
guinis, and pus corpuscles, made up of living or dead leucocytes, 



20 ESSENTIALS OF SURGERY. 

Name the varieties of pus. 

Laudable. Thick and cream-like ; this variety comes from 
ordinary acute inflammation in healthy subjects. 

Sanious. Thin, reddish, mixed with blood. From malignant 
disease, chronic ulcers, etc. 

Ichorous. Thin, watery, irritating. From chronic ulcers, 
bone disease, etc. 

Curdy or cheesy. Contains flakes of degenerated fibrin. From 
chronic abscesses connected with bone disease. 

Gummy. Thick and ropy. From syphilitic abscesses. 

Contagious pus. Muco pus, etc. 

What becomes of pus ? 

It may be disintegrated and absorbed ; it may be discharged ; 
its more liquid portions may be absorbed, while the solid portions, 
together with the affected tissues, undergo fatty disintegration 
and remain as a putty-like mass, this constitutes caseation. 

Name the varieties of suppuration. 

Circumscribed. Diffuse. The diffuse may be superficial as in 
the cases of coryza and dysentery ; or deep as in cellulitis. 

What are the symptoms of acute inflammation? 

Fever, together with redness, heat, swelling, pain, alteration of 
function and nutrition. 

What are the characteristics of inflammatory redness ? 

It is persistent ; if the capillaries are emptied by pressure with 
the finger the redness instantly returns on removal of the pressure. 
The shade of color depends upon the rapidity and freedom of 
the circulation ; if dark or bluish it denotes obstruction or stasis. 
Copper-red often denotes syphilitic inflammation. Rose-red 
streaks along the course of the lymph vessels denote lymphan- 
gitis. A dusky-red tract in the course of a vein indicates phlebitis. 

At what portion of an inflammatory area is heat most marked? 

At the focus or centre. 

Describe inflammatory swelling. 

It is due to the increased amount of blood in the part, to pro- 
liferation, and to exudation. It is soft in acute, hard in chronic 



INFLAMMATION. 21 

inflammations; is especially well marked in loose connective 
tissues. Its limitations by fascia may indicate the seat of 
inflammation. 

Describe inflammatory pain. 

It is persistent, increased by pressure, by motion, and by a depend- 
ent position of the part, and accompanied by the signs of inflam- 
mation. Is mainly due to mechanical injury to the nerves from 
the swelling. Most intense in dense structures. May be felt in 
regions remote from the inflamed area ; instance, the knee pain 
of coxalgia or the shoulder pain of hepatitis. 

Describe inflammatory alteration of function. 

Secretions are perverted or abolished. Reflexes become 
greatly exaggerated ; instance, the tenesmus (straining) of 
dysentery, the strangury of cystitis, the convulsions of teething, 
Non-sensitive parts become hyper-sensitive ; instance, the pain 
of peritonitis or of teething. 

Describe the constitutional symptoms of inflammation. 

Fever. May be sthenic or asthenic in type. 

1. Sthenic inflammatory fever. 

a. Circulatory symptoms. Full, strong, rapid pulse, flushed 
face, injected conjunctivae. 

b. Nervous system. Increased temperature, 100° to 103°, head- 
ache, lumbar pains, troubled sleep, special senses often hyper- 
sesthetic. 

c. Glandular system and alimentary tract. Secretions dimin- 
ished and scanty ; dark colored irritating urine of high specific 
gravity. Anorexia — heavy white or yellowish coating on the 
tongue. Constipation. 

2. Asthenic inflammatory fever. The general symptoms are 
the same as those of the sthenic type, except there is profound 
depression in place of over action, and the patient shortly falls 
into the typhoid, condition. Pidse feeble, rapid, and compres- 
sible. Temperature fluctuating from 99° or 100° to 103° or even 
105.° Mental condition dull and torpid, or delirious and busy. 
Tongue dry, with brown or black coat. 



22 ESSENTIALS OF SURGERY. 

How do you treat inflammation ? 

Locally and constitutionally. 

Give the local treatment of inflammation. 

Bemove the cause. Best, either general by putting the patient 
to bed, or local by the employment of splints and bandages. 

Position. Elevation with relaxation of all structures by posi- 
tion. 

Cold, may be employed with or without moisture ; ice-bag, 
irrigation, rubber tubes, cold compresses, and evaporating 
lotions. Use in the beginning of acute inflammation. 

Heat, may be combined with moisture ; hot cans or bottles, 
poultices, spongio piline, irrigation, baths, douches. 

Local depletion. Cups, leeches, and scarification. 

Counter-irritation. Tr. iodin., mustard plaster, turpentine, 
chloroform liniment, actual cautery, seton, issue. 

Vesication. Fly blister, cantharidal collodion. 

Pressure. Either direct or on the main bloodvessel of the part. 

What are the contraindications to the use of cold in inflam- 
mation? 

It should not be employed where there is great impairment 
of vitality, either local or general, where it is disagreeable to 
the patient, after inflammation is fully established, or in the 
extremes of life. 

How does heat control inflammation ? 

It restores tonicity to the bloodvessels, increases the rapidity 
of the circulation, hastens resolution, and is a powerful vitalizer. 

Under what circumstances are heat and moisture indicated ? 

Where there is great tension ; where sloughs or dead parts are 
to be separated ; where suppuration is taking place. 

What conditions indicate the employment of local depletion ? 

A condition of vascular engorgement so great that the vitality 
of the part is threatened ; instance, scarification in prolapsed 
hemorrhoids or acute conjunctivitis 

Describe cupping. 

If the blood is to be merely drawn to the surface, dry cupping 



INFLAMMATION. 23 

is employed. This may be accomplished by a regular apparatus, 
or by lighting a few drops of alcohol poured into a small cup or 
glass, and suddenly clapping it to the surface to be treated. A 
powerful vacuum is created, and the skin is drawn far into the 
hollow of the cup. If blood is actually to be abstracted, wet cups 
are used. Incisions are made through the skin, and free bleed- 
ing is encouraged by applying cups over these parts. 

Describe leeching. 

The Swedish leech is generally used ; it draws about f^ss 
of blood. Wash the surface of the skin carefully, apply a little 
milk or blood to it, put the leech in a wide-necked bottle, and 
press the mouth of the bottle against the surface to be bled. Let 
the leech drop off, and check the bleeding either by a pledget of 
styptic cotton, by compress and bandage, or by passing a hare- 
lip pin through the depth of the leech bite and tying around it. 

What parts should be avoided in applying leeches ? 

Leeches should not be placed over loose cellular tissue. In- 
stance, the eyelids and the scrotum. A leech should not be 
applied directly over a nerve or a blood-vessel, nor on the face. 
Areas of infection must not be leeched. 

When do you use counter-irritation ? 

As counter-irritation acts by drawing the blood from the in- 
flamed part, it may be used in the very beginning of inflamma- 
tion. It may be employed for the relief of pain, or, as inflam- 
mation is subsiding, its use may materially hasten resolution. 

Describe the application of counter-irritants. 

A mustard plaster must never be allowed to blister. Mix one 
part mustard, two parts flour, and cover with a thin film of egg 
albumen or molasses. The more severe forms of counter-irri- 
tation, the actual cautery, the seton, and the issue, are especially 
applicable to chronic inflammation. In using the actual cautery 
the part may be previously anaesthetized by freezing. The seton 
is made by passing some strands of silk or other material through 
a pinched up fold of the skin, and leaving them in place, slightly 
moving them from day to day to keep up irritation. The issue 
is an ulcer made by cautery Or chemicals, and kept open by a 
foreign body, such as a pea or a pebble. 



24 ESSENTIALS OF SURGERY. 

Describe vesication. 

This is really a powerful form of counter-irritation combined 
with depletion. Cantharides in some of its forms is generally 
used, either the cerate or cantharidal collodion. After six hours 
apply a poultice ; small blisters frequently repeated are termed 
fugitive blisters. 

What dangers attend the use of cantharides ? 

It may be absorbed and produce strangury, i. e., inflamma- 
tion of the genito-urinary tract, attended with great pain, and 
constant straining to pass water, with the evacuation of a few 
drops at a time. Treat by opium and belladonna suppositories, 
demulcent drinks, warm sitz baths, and leeches. Avoid by re- 
moving the blister after six hours and applying a poultice, or by 
incorporating camphor with the cantharidal cerate. 

In old and debilitated persons extensive sloughing may follow 
the use of blisters. 

When is pressure used ? 

Either in the very beginning, or after the inflammatory swell- 
ing has reached its height. It supports the bloodvessels, pre- 
vents exudation, and hastens resolution. The ordinary or the 
rubber bandage may be employed. Often the sand bag or shot 
bag is of service. 

Give the constitutional treatment of inflammation. 

1. Bleeding or general depletion. To be employed only in the 
strong and plethoric at the beginning of an attack, and where 
life or the vitality of an important organ is threatened by the 
violence of the congestive symptoms. Instance, incipient menin- 
gitis or pulmonitis. Place the patient in a semi-recumbent pos- 
ture, tie a cord or bandage about the middle of the arm, making 
enough tension to completely stop the venous circulation, tho- 
roughly disinfect the skin in the region of incision. Under all 
antiseptic precautions divide the median cephalic vein, and 
when sufficient blood has been drawn close the wound with 
a compress of iodoform gauze ; remove the fillet from the arm, 
apply a small antiseptic dressing, and put on a tight spiral re- 
versed of the upper extremity, carrying the hand in a sling. In 



INFLAMMATION". 25 

case of brain congestion bleed from the external jugular. Bleed 
till the pulse becomes soft and slow. 

2. Cardiac sedatives. Used where the pulse is full and bound- 
ing in acute inflammation. Tr. aconit. rad. gtt. ij, or tr. verat. 
vir. gtt. v, hourly. Ex. gelsem. fl. Tltv every two hours. Care- 
fully watch the effect of cardiac sedatives, especially aconite. 

3. Diaphoretics and diuretics. Applicable to nearly all forms 
of inflammatory fever. Liq. amnion, acetat. or mist. pot. cit. 
fgss, spirit, seth. nit. f^ss well diluted, or pot. nit. gr. v, every two 
hours. Citrate of caffein or infusion of digitalis may also be given. 

4. Cathartics. In the beginning of an acute attack of inflam- 
mation the bowels should be thoroughly cleared. This may be 
effected by blue mass gr. x, followed in six hours by a seidlitz 
powder, or calomel gr. £, sod. bicarb, gr. iij, repeat every hour 
till evacuation, or liquorice powder 3j. Keep the bowels regu- 
lated by Janos or Carlsbad water. 

5. Antipyretics. Quinine gr. xx, antipyrine gr. xv, antifebrine 
gr. v, phenacetine gr. x, or guaiacol locally. Not to be used 
unless the fever exceeds 105°. 

6. Anodynes. Morphia for acute pain, gr. \ hypodermically. 
Bromide and caffein for headache. Chloral and bromide for 
restlessness. 

7. Stimulants. Always in the asthenic or typhoid form of sur- 
gical fever. Where there are symptoms of depression, brandy, 
whiskey, or wine, given at regular intervals with the food. 

8. Tonics. After the acute stage has passed, tr. cinch, comp. 
elix. calisay., or quinine with iron and strychnia. 

9. Diet. Water and cracked ice for two or three days if the 
symptoms are very acute, and the affection not liable to termi- 
nate in the typhoid condition. Follow by milk taken in small 
quantities and at regular intervals. As the fever subsides the 
diet can be rapidly increased. For adynamic fever fullest diet 
the patient can digest from the first. Milk three pints daily 
with malt, oyster juice, raw oysters, peptonized raw-meat juice, 
liquid peptonoids, beef tea, etc. 

What symptoms call for the use of stimulants ? 

A weak pulse and dry tongue, particularly if associated with 



26 ESSENTIALS OF SURGERY. 

delirium. The guide as to the quantity to be employed is the 
pulse ; if it becomes slower and fuller the stimulants are doing good. 

What are the symptoms of chronic inflammation ? 

The same as in acute but less marked ; any or all of the 
cardinal symptoms may be so slight as to escape notice. 

What are the causes of chronic inflammation ? 

Preceding acute inflammation. Long continued local irrita- 
tion or functional activity. Constitutional weakness or diathesis. 

What is the pathology of chronic inflammation ? 

A large amount of plastic lymph is effused and undergoes 
partial organization, causing considerable induration. This in- 
duration greatly slows the circulation by compressing the blood- 
vessels. The infiltrated tissues undergo fatty degeneration and 
may break down forming cold abscesses. 

How do you treat chronic inflammation ? 

1. Local. Bemove cause. — May be sequestrum or foreign body. 
Best, general, in bed ; local, by splints and bandages. Local de- 
pletion. — By leeches and scarification. Vesication. — Small and 
frequently repeated blisters. Counter-irritation. — Actual cautery, 
setons, issues. Alteratives. — Tr. iodin., unguent, iodin. comp., 
unguent, hydrarg. cum belladon. Irrigation and pressure. — 
Apply a tight roller bandage and keep wet by cold or hot irri- 
gation. This is the most efficient local treatment of chronic 
inflammation. Massage — Electricity. 

2. Constitutional.— Fresh air, generous diet, stimulants, and 
tonics. Mercury, iodine, cod-liver oil, and iodide of iron. 

When must mercury be avoided ? 

In tubercular and broken down constitutions. 

How is mercury given? 

Hydrarg. chlor. mit. gr. |, Dover's powder gr. ij., give every 
two hours. Mainly used in head injuries or inflammations, also 
advised in inflammation of all serous membranes. 

What is meant by salivation? 

The constitutional effect of a persistent overdosing with mer- 



INFLAMMATION. 27 

cury. Early symptoms, a foetid breath followed by tenderness of 
the gums, noticed on chewing. Metallic taste in the mouth. 
Copious flow of saliva. Often colic and bloody stools. 

How do you treat salivation ? 

Stop the mercury, open the bowels, use a mouth wash contain- 
ing tr. myrrh, and pot. chlor. Administer belladonna or atropia 
in fairly full doses, and give hot-baths. 

Abscess. 

What is an abscess ? 

A collection of pus surrounded by a wall of lymph. An ab- 
scess is a hollow ulcer. An abnormal cavity containing pus. 

Describe the formation of abscess. 

From excessive or continued irritation there is an exuda- 
tion so copious that not only are the lymph channels blocked, 
but there is absolute blood stasis and coagulation ; the central 
portion of the exudation and the involved tissues perish form- 
ing pus because of the action of pus cocci; the peripheral por- 
tions, however, are not absolutely cut off from nutrient blood : 
they undergo organization, and form around the central part a 
bank of organized lymph or granulation tissue ; this serves a 
double purpose : to prevent the extension of the suppurative 
process, and to provide for the healing of the abscess when the 
pus is evacuated. The direct cause of the pus formation is the 
presence of micro-organisms in the exudate. 

What symptoms denote the formation of an abscess ? 

Throbbing pain. Increase in swelling. Color darker, surface 
at times glazed. (Edema of skin. Tendency to point. Fluc- 
tuation, elicited by palpation, percussion, and pressure. Rigors 
and fever. 

In what direction does an abscess point ? 

In the direction of least resistance. This is usually, but not 
always, towards the surface. 

What local symptoms point to deep suppuration ? 

Pain, oedema, and dark discoloration. 



28 ESSENTIALS OF SURGERY. 

How do you treat an acute abscess? 

JSndeavor to abort by the use of heat (110°), cold, local de- 
pletion or blisters. It is a waste of time to poultice, and we 
should open early. Open under antiseptic precautions, wash 
out the cavity with bichloride solution 1 : 2000, drain, and apply 
an antiseptic dressing. 

How do you open an abscess ? 

If superficial, with one quick cut. If deep, make an incision 
with the scalpel to the deep fascia, through this a director is 
passed and forced on till it enters the abscess cavity. A pair 
of dressing forceps, closed, is carried along the director ; by open- 
ing these and drawing out forcibly a free opening is made without 
endangering bloodvessels (Hilton's method). In evacuating 
pus, bear in mind that any violence, which breaks down the 
organized walls of lymph or granulation, retards healing; hence 
if pus is squeezed out it must be by means of gentle pressure 
made with pledgets of cotton. 

In what regions must abscesses be opened before fluctuation is 
detected? 
1. Ischiorectal, to prevent pointing into the rectum (path of 
least resistance). 2. Perineal. 3. Palmar. 4. Tonsillar. 5. 
Postpharyngeal. 6. Any abscess near important bloodvessels 
or beneath deep fasciae. 

What circumstances may retard the healing of abscess after 
incision ? 

1. Want of free drainage. To remedy, enlarge the opening, 
or make another in a more dependent position, or insert drain- 
age tube. 

2. Imperfect apposition of the granulation walls, hemorrhage, or 
break in the limiting walls allowing an infiltration of pus into the 
surrounding tissue. Treat by compress and bandage. 

3. Indolent granulations or constitutional weakness. Treat 
locally by stimulating applications. Cu. sulph. or argent, nit. 
gr. iv to aq. f ^j, iodoform ; the constitutional condition must be 
remedied by tonics and stimulants. 



INFLAMMATION. 29 

How does a chronic abscess differ from an acute one? 

The course is slow, the signs and symptoms are slight or want- 
ing. The tendency to point is not marked, pus accumulating at 
times to an extraordinary extent before the skin shows signs of 
yielding. The pus corpuscles are broken up and there are few or 
no micro-organisms to be found on microscopic examination. The 
granulation wall is very thick, partially organized into connec- 
tive tissue, and showing little tendency toward the production 
of healthy granulation. The condition is one of passive conges- 
tion rather than active hyperemia, hence the name congestive 
abscess ; called also cold abscess from the slight development of 
inflammatory heat. 

What are the constitutional symptoms of chronic abscess? 

May be slight or wanting till the abscess bursts or is opened, 
when hectic quickly develops ; by this is meant a daily rise in 
temperature, often preceded by rigors, and followed, after some 
hours, by profuse sweating with subsidence of fever. Emaciation 
is continuous and rapid. 

How do you treat a chronic abscess ? 

Generous diet, stimulants, tonics, iodide of iron, and cod-liver 
oil. Unless the abscess is stationary, and giving no trouble 
either directly or indirectly, open at once under strictest anti- 
septic precautions. Aspiration followed by pressure may succeed 
when there is no bone involvement. Usually incision will be 
necessary ; the cut must be as far removed from sources of con- 
tagion as possible (hence open psoas abscess above Poupart's liga- 
ment), and planned to thoroughly drain the cavity. Irrigate 
daily with iodoform suspended in olive oil, 1 per cent, carbolic, 
or 1 : 6000 bichloride. Apply each time a complete antiseptic 
dressing, providing cushions of jute, oakum, sea moss, or cotton 
to receive and absorb the discharge. 

What are the chief characteristics of tubercular abscess? 

They are chronic, have a tendency to caseation and long-con- 
tinued discharge, and affect mainly bones, lymph glands, and lungs. 



30 ESSENTIALS OF SURGERY. 

How do you treat tubercular abscess ? 

Thoroughly remove the affected area by means of the knife or 
curette. Inject 10 per cent, iodoform-olive oil into the infiltrated 
tissues. 

What is a residual abscess ? 

An abscess which appears at or about the seat of a former 
suppuration ; commonly due to caseous masses. 

What is a sinus ? 

A suppurating canal, left by an imperfectly healed wound or 
abscess. 

What is a fistula? 

A communication between two mucous cavities, or between a 
mucous cavity and the external air, by means of a suppurating 
canal. 

How do you treat sinus and fistula? 

Kemove all irritating causes and bring the walls together by 
pressure, employing stimulating injections (silver, copper, zinc) ; 
or freely lay open, and by gentle packing with iodoform gauze, 
cause healing from the bottom. 

How do you diagnose abscess from aneurism ? 

Should abscess occur in the immediate neighborhood of a 
large vessel the history will be one of previous inflammation ; 
the pulsation of abscess is a simple lifting impulse, not an expansive 
throb ; the abscess may be absolutely isolated from the artery by 
manipulation ; pressure on the distal side does not increase the 
tension of abscess, nor does pressure on the proximal side di- 
minish it. Abscess gives no thrill, no bruit ; finally, if there be 
the chance of a doubt, the exploring needle gives pus from the 
abscess. 

How do you distinguish encephaloid disease from abscess? 

In soft cancer the course is chronic, and at first painless ; it 
presents multiple eminences, has large purple veins coursing 
over it, and is elastic rather than fluctuating. 



INFLAMMATION. 31 

Ulceration. 

What is ulceration? 

The molecular death of tissues, leaving a solution of continuity, 
and accompanied by a discharge. 

What are the causes of ulceration ? 

1. Predisposing, quantity and quality of the blood, together with 
the freedom and rapidity of the circulation. 

2. Excitiug, irritation, physical or chemical. 

What is the pathology of ulceration? 

As for abscess ; from over-crowding, the tissues and effused 
matter about the focus of inflammation perish, the peripheral 
areas become vascularized, and are converted to granulations. 

What is a granulation ? 

A capillary loop about which are clustered leucocytes, held 
together by a slight amount of intercellular material. 

Describe healthy granulations. 

Cherry-red, non-sensitive, elastic, and discharging laudable 
pus. 

By what processes is ulceration healed? 

By granulation and cicatrization. While the dead central 
parts of the ulcer come away as a thin discharge called ichor, 
the exudation beneath and around is becoming vascularized, 
capillary loops shoot out toward the surface (the direction 
of least resistance) ; about each loop clings a cluster of living 
leucocytes, and a surface of healthy granulation is established, 
discharging laudable pus. Cicatrization now begins, the sur- 
rounding skin sinks to the level of the granulations, and its epi- 
thelial cells undergo segmentation and grow as a ring about the 
periphery toward the centre of the ulcer ; this skinning over is 
denoted by a blue film, and while it is extending the ulcer is 
contracting, from conversion of leucocyte to fibrous tissue ; this 
contraction goes on long after the ulcer is entirely healed, and 
may cause great deformity. The process of skinning and con- 
traction is called cicatrization, the result is a cicatrix or scar. 



32 ESSENTIALS OF SURGERY. 

Describe a cicatrix. 

At first blue, it finally becomes white, the progressive contrac- 
tion of the connective tissue squeezing all the blood from the 
part. A cicatrix has neither nerves, glands, lymphatics, nor 
hair ; it readily ulcerates, and is slow in healing. 

What is an ulcer ? 
A surface of granulations. 

Name the varieties of ulcers. 

1. Local. 

a. Simple healthy or healing. 

b. Complicated or spreading. 

2. Constitutional, strumous, syphilitic. 

Of the complicated or spreading we have the fungous, the 
oedematous, the inflamed, the sloughing, the phagedenic, the 
indolent ulcers. 

Describe a simple or healthy ulcer. 

Granulations, healthy, cherry-red, small, uniform, not painful. 
Discharge, laudable pus in small quantity ; if the ulcer has been 
treated antiseptically the discharge is serum. Shape, oval, 
regular. Edges, gently sloping, moderately indurated, showing 
the blue line of beginning skinning. Surrounding skin soft and 
flexible. 

Give the treatment of simple ulcer. 

In the forming stage, abort or limit by rest, elevation, local de- 
pletion, and cold ; at the same time treating the rather high 
constitutional symptoms by withholding food, giving abundance 
of water, iced drinks, or cracked ice, opening the bowels, and, 
if necessary, administering morphia hypodermically to control 
the pain. 

When disintegration is evident hasten the separation of the 
dead from the living tissues by warm antiseptic poultices 
(sponges, lint, or gauze soaked in weak bichloride solution 1:6000, 
and covered in by waxed paper and a bandage). Milk diet. 
When the dead part is separated leaving a surface of healthy 
granulations, cleanse with sterilized salt solution 5 per cent., or 



INFLAMMATION. 33 

very weak antiseptic lotions, bichloride 1 : 10,000. Cover with 
protective or gutta-percha tissue, and apply a light antiseptic 
dressing, finishing with moderately firm pressure by a roller 
bandage. Full diet. A healthy ulcer heals kindly under nearly 
any dressing. 

Describe the inflamed ulcer. 

A simple ulcer may become converted to an inflamed ulcer by 
any of the local or constitutional causes which give rise to in- 
flammation. Instance, debauch, injury, etc. Granulations, at 
first bright red, become dusky, finally break down forming a 
gray, ragged, sloughing surface. Discharge, very profuse, con- 
sists of pus and the debris of broken down tissue. Edges, irregu- 
lar, deep, sharply cut, indurated. Surrounding skin, red and 
cedematous. Pain and tenderness acute. Constitutional symp- 
toms well marked. 

Give the treatment of inflamed ulcer. 

A saline cathartic in the beginning of the attack. Rochelle 
salts 3j. Rest in bed with elevation of the part. Local deple- 
tion by leeches, or incisions into the edge of the ulcer. Hot 
antiseptic poultices. Low diet, opium to relieve pain. 

Describe the sloughing ulcer. 

Yery commonly associated with venereal disease. This is 
but an aggravated inflamed ulcer, and is characterized by the 
same peculiarities, with the addition that there is a rapid spread' 
ing attended by destruction of visible portions of the tissues which 
are thrown off as offensive gray sloughs. All symptoms, both 
local and general, are aggravated. 

How do you treat sloughing ulcers ? 

Tonic and stimulant. Constitutional condition must receive 
particular attention, as all sloughing processes tend rapidly to- 
wards exhaustion. Charcoal or antiseptic poultices till sloughs 
come away. Spray of hydrogen peroxide. 

Describe the phagedenic ulcer. 

This form is an aggravated sloughing ulcer. Found only in 
venereal disease or in patients with profoundly depressed con- 
3 



84 ESSENTIALS OF SURGERY. 

stitution. The granulations are absent, being replaced by gray 
sloughs ; the discharge is ichorous, containing shreds of dead 
tissue ; the edges are ragged, dusky red, and extensively under- 
mined ; the surrounding skin cedematous, red. The extension is 
very rapid, may destroy an entire organ (the penis), and is at- 
tended by severe constitutional symptoms of the adynamic type. 

Give the treatment of phagedenic ulcer. 

Clear the bowels. Rich nourishing diet, stimulants, tonics, 
opium. Continuous warm baths during the day, with iodoform 
dressing at night. Or the ulcer may be treated by charcoal 
poultices and antiseptic washings till sloughs are separated. 

Describe the serpiginous ulcer. 

This is really a phagedenic ulcer. Its course is slow but per- 
sistent ; it may produce most extensive destruction of tissue. 

Treatment. Constitutionally, supporting ; locally, actual cau- 
tery, or as for phagedenic ulcer. 

What is an irritable ulcer ? 

An ulcer which presents the features of an inflamed ulcer, to- 
gether with great pain, out of all proportion to its apparent 
cause. This pain is probably due to the stretching of small nerve 
branches. 

Treatment. Subcutaneous section of the nerve branch sup- 
plying the ulcerating area, or applications of chloral gr. xx., or 
argent, nit. gr. xx. to the ounce of water. 

What are fungous and cedematous ulcers ? 

In the fungous ulcer the granulations grow above the level of 
the surrounding skin, and may spread out as a cauliflower or 
mushroom-like growth ; they bleed readily. Cause, obstruction 
to venous return from undue contraction of surrounding tissues. 

The cedematous ulcer is characterized by large, pale, flabby, 
watery granulations which have a tendency to become fungous. 
Cause, venous obstruction combined with struma or systemic 
depression. 

How do you treat fungous and cedematous ulcers? 

Astringent applications. Powdered alum, glycerole of tannin, 



INFLAMMATION. 35 

followed by compression applied by means of imbricated adhesive 
straps and a tight roller bandage. 

Excision. If these means fail, or if the granulations have 
assumed a mushroom-like growth, shave off level with the sur- 
face, dust with iodoform, and apply an antiseptic dressing, with 
a tight roller bandage over the whole. 

Describe the indolent, callous, or chronic ulcer. 

Granulations. Never healthy, usually small, scanty, and 
brickdust-red ; frequently fungous or oedematous. 

Discharge. Ichorous or sanious pus. 

Edges. Everted or inverted, irregular, never gently sloping. 
Blue line of skinning absent. 

Surrounding skin. Discolored, often eczematous and densely 
indurated. 

Occurs. After middle age, and in those whose occupation 
requires long standing. 

Favorite seat. The outer surface of the lower third of the leg, 
because : 1 . It is an exposed portion. 2. There is little cellular 
tissue separating skin from bone. 3. Its dependent position 
favors passive congestion and thrombosis. 

Course. Exceedingly slow, may last many years. 
, Constitutional symptoms. None. 

The eczematous and varicose ulcers are simply chronic ulcers 
with marked development of the affections from which they 
take their names. 

What prevents chronic ulcers from healing ? 

From long congestion the bank of lymph becomes redundant, 
and is, in part, converted to imperfect fibrous tissue, which, by 
pressure upon the vessels, blocks the circulation. They may 
fail to heal because of adhesions to the deeper structures, be- 
cause of absence of granulations, or because the epithelium 
does not grow over it. 

How do you treat chronic ulcers ? 

Cause the absorption of the obstructing bank of lymph. Healing 
granulations will then appear. This is accomplished by heat, 
moisture, and pressure. 

Treatment.— Soak the ulcer for two hours at night in warm 



36 ESSENTIALS OF SURGERY. 

2 per cent, boric acid solution, followed by a thick poultice 
(boric acid solution and ground flaxseed, the surface being 
coated with boric ointment), well protected by oiled silk, or 
waxed paper, so that it may not cake before being removed. In 
the morning, substitute for the poultice strips of lint wet in 
boric lotion, and imbricated over the affected region ; cover 
these strips with waxed paper, and apply very carefully over 
the whole a roller bandage, taking in the foot and going as high 
as the knee : at night remove the dressing and soak again. Con- 
tinue this treatment for three or four days, or until the bank of 
induration is softened, then strap. Use adhesive plasters cut in 
strips one inch wide, and long enough to extend nearly around the 
limb. After elevating the leg and allowing the blood to drain 
out, begin the dressing by applying the first strap two inches 
below the lower border of the ulcer, making firm pressure as it 
is carried around the leg or foot ; the next strap is applied nearer 
the ulcer, overlapping the first for two-thirds of its width ; so 
continue till the ulcer is reached, when the straps must overlap 
as before, but in applying them, first fasten one end, then press 
the edges of the ulcer together, diminishing its size as much as 
possible, and secure it in this position by continuing the strap 
firmly across it and around the limb. The straps must entirely 
cover in the ulcer and an area two inches above and below. 
Over the straps apply a layer of lint, and cover in the whole by 
a closely fitting roller bandage. The dressing is removed and 
reapplied as required by the amount of discharge. If this 
method cannot be carried out, apply a Martin's rubber bandage 
directly to the skin, removing it at night ; wash the leg night 
and morning in boric lotion. 

A blister applied to the entire ulcer and surrounding skin may 
cause the induration to disappear. Incisions, or shaving off of the 
induration may be required. 

What are the characteristics of tubercular ulcers ? 

Favorite seats neck and groin. Chronic, painless, discharge a 
thick oily pus, granulations cedematous, skin extensively un- 
dermined, and overhanging the ulcer in the form of loose blue 
flaps. 



INFLAMMATION. 87 

What ulcers are mostly found on the leg ? 

Varicose, traumatic, and syphilitic. A non-traumatic ulcer 
of the upper third of the leg is mostly syphilitic. 

What ulcers chiefly affect the face ? 

Rodent ulcers, and those due to lupus, syphilis, or epithelioma. 
The rodent idcer is distinguished from the epitheliomatous from the 
fact that it does not involve lymphatic glands, nor induce secon- 
dary deposits ; its course is very slow ; its base is smooth and 
glossy, with little or no discharge ; its edges moderately indu- 
rated, smooth, round, and rolled over. 

Describe skin grafting. 

By skin grafting is meant the placing on granulating sur- 
faces of healthy epidermis for the purpose of hastening cicatri- 
zation and preventing subsequent contractions. It is chiefly 
applicable where the granulating surface is large, or conspicu- 
ously placed, or slow in healing. The granulations must be 
healthy, discharging very slightly, and preferably aseptic. This 
may be accomplished by washing with weak bichloride solutions 
and dressing antiseptically for several days before the operation. 
The area from which the grafts are taken should be thoroughly 
washed with soap, water, and bichloride, 1 : 1000, followed by 5 
per cent, sterilized salt solution (sodium chloride 5 parts, water 
95 parts, boil for one hour). By means of a scalpel, scissors, or 
a razor, small or large pieces of cuticle, including the rete rau- 
cosum, but not the corium, are removed, and placed, fresh sur- 
face down, on the granulations, from which all antiseptics have 
previously been washed by liberal salt solution irrigations. 

Apply protective wet in salt solution, and either a sterile, or 
an antiseptic dressing, covering in the whole with a tight roller 
bandage. By this method strips of skin, £ in. by 2 in., may be 
transplanted and retain their vitality. The grafts should be 
taken from young healthy persons. 

The grafting of a piece of considerable size is the operation 
of Thiersch, while the planting of a number of small pieces is 
the procedure of Reverdin. Krause transplants the entire thick- 
ness of the skin. 



38 ESSENTIALS OF SURGERY, 



Mortification. 

What is mortification or gangrene ? 

Death in mass. 

What is a slough or sphacelus? 

That portion of tissue affected by mortification. 

What are the causes of gangrene ? 

1. Direct violence from physical or chemical agencies. 

2. Deficient blood supply from inflammatory engorgement, weak 
circulation, diseased vessels, embolus, or thrombus. 

3. Bacterial infection. 

Name the two commonest forms of gangrene. 

1. Acute or moist. 2. Chronic or dry. 

What structures resist gangrene ? 

Arteries (hence thrombi form before their walls are disinte- 
grated, and bleeding is prevented), nerves, tendons, and bones. 

How is gangrene limited ? 

By a reactive inflammation. A wall of granulation is thrown 
out, at the expense of the healthy tissues, by which the slough is 
separated from the living parts. 

What first indicates the limit of gangrenous processes ? 

The line of demarcation. A red line due to capillary conges- 
tion, indicating the beginning of inflammatory reaction. 

What follows the line of demarcation ? 

The line of separation. A line of ulceration or granulation. 

What are the general indications in the treatment of all gan- 
grenous processes ? 

Keep the dead or dying part thoroughly aseptic. Cleanse, dis- 
infect, and wrap in thick layers of antiseptic wool, cotton, or 
gauze. Carefully guard against the invariable tendency to ady- 
namia. 



INFLAMMATION. 39 

What are the symptoms of acute mortification ? 

Synonym : Local traumatic gangrene. 

Usually acute inflammatory symptoms with evidence of great 
local congestion, and intense burning pain. The pain ceases, 
there is loss of sensation, of power to move the part. The temper- 
ature falls, and pulsation of the arteries cannot be detected. The 
color, at first dusky-red, turns to blue, to purple, to dirty brown, 
or black. Blebs form, the course of the superficial vessel is 
marked by lines of dark discoloration. Even yet vitality may be 
restored. If, however, the cuticle separates from the derm and 
can be rubbed off by light pressure, if there is crackling, emphy- 
sema, and foul odor, death is absolute. 

The constitutional symptoms are those of inflammatory fever, 
but of an adynamic or typhoid type. Rapid, feeble pulse, low 
delirium, etc. 

How do you treat acute mortification ? 

Preventive. Believe tension. Remove tight bandages. Evac- 
uate retained discharges. Freely incise inflammatory congestions. 
Massage. Render the part aseptic ; wrap in antiseptic wool. 

If the slough is thoroughly established, and is putrid, char- 
coal poultices or wet bichloride dressings may be used ; other 
wise, dry antiseptic dressings are indicated. 

Amputate when the line of demarcation is formed. (In the hand 
and foot spontaneous amputation generally gives a better stump 
than the surgeon's knife.) 

Constitutional treatment : Yery free stimulation, full nourishing 
diet, quinine, and opium. 

What is spreading traumatic gangrene ? 

An acute, rapidly spreading, moist gangrene, dependent on a 
specific micro-organism. It appears shortly after severe trau- 
matism, and before the line of separation can form, extensively 
invades the tissues, and causes death from exhaustion or septic 
poisoning. All local inflammatory symptoms may be absent ; 
swelling, discoloration, and loss of temperature circulation and 
sensation, denoting the extension of the process. In other cases, 
an inflammatory redness and induration precede the gangrene. 
The constitutional symptoms are profoundly adynamic. 



40 ESSENTIALS OP SURGERY. 

How do you treat spreading traumatic gangrene? 

Immediate amputation through healthy tissue, high up. 

What is hospital gangrene ? 

An epidemic, contagious, gangrenous process, dependent upon 
the presence of micro-organisms, which destroys granulations, 
attacks the tissues lying about and beneath them, and rapidly 
produces extensive sloughs. 

Give the symptoms of hospital gangrene. 

As for acute mortification. The surface of a wound, or its 
margins, are rapidly converted into an extensive slough, there is 
surrounding oedema and congestion, the discharge is foul, the 
process rapidly extends. 

The constitutional symptoms are adynamic ; high temperature 
at first, with weak, quick irregular pulse, wet surface, and, fre- 
quently, muttering delirium. 

What circumstances predispose to attacks of hospital gan- 
grene ? 

Over-crowding, deficient ventilation, want of proper nourish- 
ment, or any depressing cause. 

How do you treat hospital gangrene? 

Isolate the patient. Break up the sloughs by thrusting closed 
dressing forceps through them, and withdrawing the forceps 
opened. In these openings make a thorough application of pure 
bromine, nitric acid, or other escharotic. Dress with anti- 
septic charcoal poultice, and subsequently observe the most rigid 
asepsis in regard to wound treatment. 

Constitutionally give stimulants, free diet, quinine, iron, and 
opium. 

What is cancrum oris ? 

Synonym. Gangrenous stomatitis. 

It is a gangrenous ulcer of the cheek or gums, occurring in 
poorly nourished children. It is frequently developed after an 
attack of measles, scarlet fever, or typhoid fever. It usually 
appears opposite a rough or decayed tooth, which has caused 
an abrasion. It is seen in the mouth as an offensive, sloughing, 



INFLAMMATION. 41 

punched out ulcer ; on the external surface of the cheek as a 
glazed, dusky red, indurated spot, which is shortly converted into 
a black slough, causing perforation, and extensive destruction 
of tissue. The constitutional symptoms are those characteristic 
of all gangrenous processes. 

How do you treat cancrum oris ? 

Thoroughly cauterize with, nitric acid. Wash at intervals with 
boracic acid lotion, or tr. myrrh. Give internally stimulants, 
rich milk in abundance, malt, iron, and quinine. Repair de- 
formity by subsequent plastic operation. 

What is noma pudendi? 

A gangrenous process similar to cancrum oris, attacking the 
genitals of female children. Treatment. As for cancrum oris. 

What is a bed sore ? 

A sloughiug ulcer, due to pressure, appearing on the bony 
prominences of the weak and badly nourished. 

How do you treat bed sores ? 

Clear away the slough by charcoal poultices, wash and dress 
antiseptically, relieve the part from pressure by pads, pillows, 
or air cushions. 

Describe a furuncle. 

Definition, A circumscribed inflammation of the skin and 
subcutaneous tissue, terminating in suppuration, and the forma- 
tion of a central slough or core. Synonym. Boil, 

Occurs. In crops, on the neck, nates, and back of the young. 

Causes. Systemic depression, and the rubbing into the ducts 
or hair follicles of the skin of a micro-organism. 

Begins as a red pimple, usually with a hair in the centre, in- 
creases rapidly in size, causing a purple-red, very painful 
swelling which may undergo resolution (blind boil), or open, dis- 
charging the central core. 

Treatment. 1. Pull out the central hair, wash thoroughly 
with bichloride, apply 50 per cent, ichthyol ointment. 2. Inject 
with Tfl.v. of a 10 per cent, solution of carbolic acid. 3. If in- 
flammatory symptoms increase in severity, apply spongio piline 



42 ESSENTIALS OF SURGERY. 

(lipped in hot boracic or carbolic acid lotion. 4. When fluctua- 
tion is evident, incise, syringe the cavity with antiseptic solution, 
and apply an antiseptic dressing, making firm pressure. 

What is a carbuncle ? 

An inflammation of the skin and subcutaneous tissues, in- 
volving a much larger surface than furuncle, and attended by 
the formation of sloughs of considerable size. 

It differs from boil in being much larger, flattened instead of 
conical, and accompanied by great surrounding oedema. The 
skin gives way in several places, sloughs of some size are dis- 
charged. Constitutional symptoms are severe. 

Occurs in the aged and debilitated. 

Cause. The rubbing in, by friction, of a micro-organism. 

Seats. Neck, back, nates. When occurring on the face or 
head it is exceedingly fatal. 

Give the symptoms of carbuncle. 

A hard, brawny, flattened, dusky-red area of induration, cir- 
cular in shape, and riddled with apertures, through which a 
gray slough can be seen. The constitutional symptoms are 
severe and of an adynamic type. 

Give the treatment of carbuncle. 

The constitutional treatment should be conducted on the plan 
indicated for all gangrenous processes. Stimulants, full diet, 
iron, quinine, and opium may be given. Locally, the affection 
may be treated by — 

1. Tight concentric strapping, leaving a central aperture for 
the escape of sloughs. 

2. Hot fomentations or poultices, the moisture being supplied 
by boracic or carbolic acid solution. Heat and moisture may 
be combined with strapping. 

3. Injections through the inflamed area, and about its periph- 
ery, of carbolic acid (5 or 10 per cent, in glycerine) ; as much 
as a half drachm may be used. 

4. Crucial incision, and removal by curetting of all the involved 
cellular tissue. The operation must be done antiseptically. 
Pack the wound with iodoform gauze, and apply a thick antisep- 
tic dressing. 



INFLAMMATION. 48 

What is the usual cause of dry gangrene? 

Synonym : Senile or chronic gangrene. 

Cause. Arterial obstruction from atheroma and thrombosis. 

What are the premonitory symptoms of senile gangrene ? 

The limb feels cold and numb; tingles and is subject to shooting 
and violent pains ; steady deterioration in health. 

What symptoms denote the onset of the disease ? 

The appearance of a black spot, usually to the inner side of 
the great toe, surrounded by a dusky-red areola, and causing an 
intense burning pain. There is a slow extension till the entire 
foot becomes hard, dry, black, and mummified. 

How do you treat dry gangrene ? 

Disinfect the part and wrap in antiseptic wool or cotton. Al- 
low a generous diet. Give tonics and stimulants ; opium two or 
three grains daily. 

Under what circumstances is amputation required in gan- 
grene ? 

When the line of separation is formed. 

Immediately, in spreading or traumatic gangrene. 

In gangrene from arterial occlusion, when the seat of the 
occlusion can be certainly determined. Instance, wound or liga- 
tion of an artery. 

In senile gangrene, if the process is slow, if there is no ex- 
haustion and no evidence of sepsis, wait a line of demarcation, 
and amputate through an area which exploratory incisions 
show is free from arterial disease. If the process is rapid, if 
there be no tendency to form a line of separation, if the patient 
is exhausted, or if there be evidences of sepsis, amputate high 
up without waiting for a line of demarcation. 



44 ESSENTIALS OF SURGERY. 

WOUNDS. 

The Germ Theory. 

Outline the germ theory. 

Putrefaction is the result of the growth of micro-organisms in 
the substance which putrefies. These micro-organisms are di- 
vided into — 

1. Non-pathogenic, or those which do not directly create dis- 
ease. 

2. Pathogenic, or disease creating. 

Among the non-pathogenic, are included those which can live 
or grow only in dead or dying matter, termed saphrophytic. 
These saphrophytic micro-organisms, entering a wound in which 
there is much pent-up discharge and dying tissue, rapidly in- 
crease, and produce certain irritating substances, called ptomaines. 
The absorption of ptomaines into the system gives rise to the 
symptoms which are characterized as septic intoxication, ptomaine 
fever, or saprxmia. 

Pathogenic micro-organisms thrive not only on dead matter, but 
invade and destroy the living tissues. They may be carried 
through the circulation to all parts of the body, increasing with 
incredible rapidity wherever deposited, destroying tissue, and 
forming fresh centres for the production of poisonous products. 
They enter the system, by a process of direct inoculation, through 
wounds. Nearly all pathogenic microbes are either micrococci 
(spherical) or bacilli (rod-shaped). 

What are the general principles of antiseptic treatment? 

Prevent wound-changes due to the presence or introduction 
of micro-organisms ; or, if such changes have begun, endeavor 
to arrest them. Since microbic changes depend upon the pres- 
ence of organisms and a soil in which they can grow, the indi- 
cations for the prevention of these changes are — 

1. Exclude all organisms from the wound. This may be ac- 
complished by most minute attention to the details of surgical 
cleanliness. 



WOUNDS. 45 

2. Bemove organisms from the wound, before they can work 
harm, by irrigation. 

3. Destroy organisms, by bichloride or other germicides. 

4. Bemove the soil in which organisms can nourish, by free 
drainage. 

5. Prevent the formation of favorable soil, by avoiding tension 
or unnecessary manipulation, and by careful dry dressing. 

What is the distinction between antiseptic and aseptic ? 

Aseptic means germ free; antiseptic means germ destroying. 
The surgeon who does not practise antisepsis cannot procure 
asepsis. An aseptic wound is the result of antiseptic treatment. 
Dressings sterilized by heat have undergone as thorough anti- 
septic treatment as those saturated with bichloride. By an 
aseptic dressing is meant the application of substances previously 
sterilized, but containing, at the time of application, no germ- 
destroying agents. Antiseptic dressings contain germ destroying 
agents. By the term " aseptic operation " we mean an opera- 
tion conducted with cleanliness, but without the introduction 
of a chemical germicide into the wound. 

Shock. 

What is shock? 

A lowering of the vital powers consequent on profound mental 
or physical impression. Shock is a vaso-motor paralysis, affect- 
ing also the heart, and chiefly the abdominal vessels. 

What are the causes of shock ? 

1. Powerful mental impressions, joy, grief, and fear. 

2. Mechanical injury; traumatism, especially of the abdomen; 
burns, scalds, cold ; gunshot, lacerated, and contused wounds. 
As predisposing causes can be classed all conditions which 
cause enfeeblement of the resisting powers. Instance, Bright's 
disease, sedentary occupation, and hemorrhage. 

What are the symptoms of shock? 

Pulse first slow, then rapid, feeble, compressible, and scarcely 

perceptible. Temperature sub-normal. 



46 ESSENTIALS OF SURGERY. 

Surface cold, pale, and wet. 

Muscular system relaxed, contractility of sphincters lost. 
Patient lies in any position in which he may be placed. Decu- 
bitus usually dorsal. Nausea and vomiting frequently present. 
Consciousness and special senses blunted. 

What is your prfignosisjn shock? 

Bad if the temperature falls below 96°, or if reaction is delayed 
twenty-four hours. 

What becomes of a patient suffering from shock ? 

He either collapses and dies from syncope or asthenia, or reacts. 

Describe reaction. 

Healthy reaction is characterized by an increase in the force, 
and a diminution in the rapidity of the heart's beat, a rise of 
temperature, a restoration of color to the blanched surface, and 
disappearance of all the characteristics of shock. In other cases 
reaction may take the form of an acute fever, with flushed face, 
injected conjunctivae, high temperature, restlessness, jactitation, 
active or muttering delirium, and a full, throbbing pulse. The 
pulse, however, is soft and compressible ; the tongue is dry and 
tremulous ; the symptoms are asthenic, and are liable to lapse again 
into profound and fatal shock. This condition is termed trau- 
matic delirium, and is a condition of under reaction from shock. 

How do you treat shock ? 

External warmth most important of all treatment. Hot bath, 
hot bricks or bottles applied along the spine, to the epigastrium, 
and about the patient's body and limbs. 

Position. Dorsal decubitus with head low. 

Medication. Atropia gr. y^ and brandy 3js, every thirty 
minutes hypodermically ; morphia gr. \ if there is great pain. 
Avoid medication by the stomach till reaction begins, as there is no 
absorption. Use stimulating enemata. Hot coffee, or hot, highly 
seasoned beef tea, may be given in small doses by the mouth. 
Hypodermoclysis or enteroclysis or venous transfusion of hotnor- 
mal salt solution. When reaction has fairly set in, stop stimidating. 

Describe the forms of traumatic delirium. 
In addition to the form described as an imperfect reaction 



WOUNDS. 47 

from shock, there is an inflammatory, a nervous, and an alcoholic 
traumatic delirium. 

The inflammatory form is characterized by fever and sthenic 
symptoms with either sthenic or asthenic condition. It develops 
in from three to five days after the injury, and is really a symp- 
tom of septic inflammatory fever. Treat as for the fever, apply- 
ing an ice cap to the head. 

The nervous and alcoholic forms of traumatic delirium have the 
same busy asthenic delirium, the soft, full, quick pulse, the 
tremulousness, and absence of fever, the difference being that 
the nervous is not caused by alcohol. 

Treatment. Stimulants, bromide, chloral, morphia. Clear 
the bowels, give plenty of nourishing liquid food highly- 
seasoned. 

What is secondary shock ? 

Symptoms coming on at varying times from the primary 
shock, and causing death from heart clot, are characterized as 
secondary shock. 

Should you operate during shock? 

Not unless it is for the relief of a condition causing, or keep- 
ing up the shock. Instance, a strangulated hernia, a bleeding 
artery, a depressed fracture of the skull. The rule is to wait 
for reaction. 

Wound Fever. 

What is primary wound fever ? 

A fever accompanying healing without suppuration. 

What are its forms ? 

Aseptic fever and traumatic or surgical fever. 

What is aseptic fever ? 

The slight febrile condition which accompanies the healing 
of aseptic wounds. The temperature may reach 102°, but it 
becomes normal in a day or two, and the rise is due to the ab- 
sorption of fibrin ferment. 

What is traumatic or surgical fever? 

The febrile state developed during the healing of wounds 



48 ESSENTIALS OF SURGERY. 

which are inflamed but not suppurating, and caused by the 
absorption of the pyrogenous products of inflammation and 
the ptomaines of bacteria. A day or two after the operation 
the temperature rises to 102° or more, and there are positive 
evidences of the febrile condition. On the third or fourth day 
suppuration occurs. The fever lasts about one week. 

What is scondary wound fever ? 

A fever arising after the establishment of suppuration, and 
especially marked when pus is pent up. 

How would you treat aseptic fever? 

The patient is very comfortable, and no especial treatment is 
required. 

How would you treat surgical fever ? 

Cut the stitches and evacuate retained fluids; either lay 
open or insert tubes after irrigation, and apply antiseptic 
dressings. 

How would you treat secondary wound fever ? 

Make counter-openings for drainage and irrigate ; use stimu- 
lants, good food, and opiates. 

What is septicaemia ? 

A poisoning by the absorption of pus cocci or their ptomaines. 
Hence, it is most liable to occur in wounds not treated antisep- 
tically, or in those which, from their depth, extent, or location, 
cannot be thoroughly disinfected and protected. Instance, 
compound fractures, wounds involving the peritoneum. 

What are its forms ? 

True septicaemia or septic infection, due to the absorption of 
the organisms and their multiplication in the blood. Sapraemia 
or septic intoxication, due to the absorption of a large dose of 
poisonous ptomaines. 

Give the symptoms of septicaemia. 

Inflammatory fever may run into septicaemia, or this affection 
may develop very shortly after the infliction of a wound. 

Temperature. Rises suddenly, and is at first very high (104°- 
106°), may shortly sink to normal or below. 



WOUNDS. 49 

Pulse. Soft, rapid, and compressible, becoming weak and 
thready. Respirations, rapid and shallow. 

Nervous condition, heavy, apathetic, somnolent. Rarely, active 
delirium. 

Tongue, dry, hard, and discolored. Teeth covered with sordes. 
At times profuse diarrhoea. Urine and fseces passed involunta- 
rily. Death in collapse. 

The wound is always unhealthy, frequently sloughing. 

The septic poisoning may be so slight in amount as to cause 
scarcely recognizable symptoms, or may, within twenty-four 
hours of the infliction of an injury, overwhelm the system. 

How do you treat septicaemia ? 

Remove the septic matter, and make the wound sterile by 
irrigation, or continuous baths with bichloride solution. Elimi- 
nate the ptomaines by a saline purge. Support the strength by 
stimulants, quinine in tonic doses, nutritious food given fre- 
quently in small quantities ; milk and malt, peptonoids, raw beef 
juice. Reduce high temperature by antipyrine, gr. x.-xv., or 
quinine, gr. xx. Intravenous use of normal salt solution may 
do good. Secure plenty of fresh air and sunlight. 

What is pyaemia? 

A septic fever, characterized by the formation of metastatic 
abscesses. Pathogenic organisms (staphylococci and strepto- 
cocci) invade the blood, and are carried from the infected area 
to all parts of the body, where they are lodged as emboli, and 
form new foci of suppuration and infection. 

What is the difference between traumatic inflammatory fever, 
septicaemia, and pyaemia ? 

Simply a difference of degree. They all depend upon the same 
cause, and are of the same nature. They occur only in infected 
wounds, and are due to the septic action of micro-organisms and 
their products. 

What are the symptoms of pyaemia ? 

Irregularly recurring attacks, characterized by a marked and 
prolonged chill, associated with high temperature (104°-106°) ; fol- 
lowed by a brief hot stage, the patient manifesting the symptoms 
4 



50 ESSENTIALS OF SURGERY. 

and signs of fever ; terminating in a drenching sweat, the tempera- 
ture quickly falling to normal or below. Several such attacks 
may occur in a day. The strength rapidly fails ; the pulse be- 
comes weak and rapid ; the tongue dry and brown coated •, 
breath mawkish ; metastatic abscesses are detected in the lungs; the 
wound is unhealthy, the discharges ichorous. 

How do you treat pyaemia? 

Thoroughly cleanse the original source of infection by irriga- 
tion, curetting, and antiseptic dressing ; if this be impracticable, 
as in osteomyelitis, amputate. Open and drain all accessible 
abscesses. Push stimulants to their fullest extent, give quinine 
in heroic doses (gr. lx. daily), milk and pressed beef-juice in small 
quantities frequently repeated. Provide for sun-light, and open 
air. 

What is hectic fever ? 

A continued remittent fever, due to septic absorption ; char- 
acterized by rigors and fever during the afternoon and evening, 
followed by profuse sweats and defervescence during the night. 
The pulse is constantly rapid, the eye bright, the cheek flushed, 
the tongue red and dry at the edges, the emaciation progressive. 
Instance, the fever of consumption. 

How do you treat hectic? 

Kemove the source of septic absorption, by resection, if it is an 
infected bone area ; by incision and curetting, if it is an abscess. 
Give tonics, stimulants, and a full nourishing diet. Change of air 
is beneficial. 



Erysipelas. 

What is erysipelas? 

An acute infective capillary lymphangitis due to the strepto- 
coccus of erysipelas. 

What is its cause ? 

A special streptococcus. 



WOUNDS. 51 

Name the varieties of erysipelas. 

1. Cutaneous or simple. 2. Cellulo-cutaneous ox phlegmonous. 
3. Cellular or diffuse cellulitis. 

Describe simple erysipelas. 

Constitutional symptoms. Kigors, headache, and fever, the 
temperature suddenly rising to 103° or 104° ; with nausea and 
vomiting. The fever shortly assumes a typhoid type. 

Local symptoms. A rash, rapidly spreading from a scratch, 
abrasion, or wound, and characterized by well defined margins, 
rosy-red hue, smooth, glazed, cedematous, slightly raised surface, 
stiffness and burning pain, frequently blebs or vesicles, involve- 
ment of nearest lymphatic glands. The eruption may suddenly 
disappear from one part to reappear in another, erysipelas 
ambulans. 

The pathogenic organism of simple erysipelas has been isolated. 
It is found blocking the lymph vessels and spaces in the spreading 
borders of the inflammation, shows up well in dry cover glass 
preparations, appearing as micrococci grouped in chains, and is 
diagnostic of erysipelas. The eruption lasts about four days in 
one part, and as it subsides is followed by desquamation. 

Give the treatment of simple erysipelas. 

If there is a distinct wound, thoroughly cleanse and drain it. 
Freely open the bowels by a saline cathartic. Milk diet for the 
first few days. Tr. fer. chlor. TTL xx. every two hours from the 
first : shortly begin quinine, in tonic doses (gr. v. to x. daily), 
stimulants, and as free a diet as the stomach will bear. 

To the eruption apply starch and zinc oxide, equal parts of 
each, and cover in with cotton-wool ; or apply a 50 per cent, 
ichthyol ointment, over which is placed salicylated cotton. 

Describe phlegmonous erysipelas. 

The skin and subcutaneous tissues are both affected ; the 
symptoms are, in general, the same as for simple erysipelas, but 
more marked. The swelling is greater, the edges not so 
sharply circumscribed, the color darker, blebs and vesicles are 
more common. 

The surface, at first densely indurated, becomes boggy in spots 



52 ESSENTIALS OF SURGERY. 

and may break down, exposing extensive sloughs. The consti- 
tutional symptoms are well marked, running shortly into the 
typhoid type. The patient may perish from pneumonia, blood 
poisoning, or exhaustion. 

How do you treat phlegmonous erysipelas ? 

Constitutionally , as in the case of simple erysipelas. A purge, 
light milk diet ; followed in a day or two by full nourishment, 
tonics, and stimulants. Iron as before. 

Locally. Applications of heat and moisture (hot antiseptic 
fomentations). Multiple incisions as soon as the part becomes 
brawny, going down to, but not through the deep fascia. Check 
hemorrhage by packing with iodoform gauze. Strict antiseptic 
dressing. 

Describe cellular erysipelas, or diffuse cellulitis. 

This is a spreading infective inflammation, which may involve 
the cellular tissues of any part of the body. Instance, the inter- 
muscular planes, the pelvic cellular tissues. 

The constitutional symptoms are the same as those character- 
izing phlegmonous erysipelas ; the typhoid condition appears 
more quickly, and septic poisoning is more commonly developed. 

The local symptoms are at first less marked than in any of the 
varieties of erysipelas. There is dense induration succeeded by 
bogginess and ending in extensive sloughing. 

Treatment as for cellulo-cutaueous. Incisions early. Stimu- 
lating and supporting treatment from the first. 

Tetanus. 

What is tetanus? 

A disease characterized by tonic spasm of the voluntary mus- 
cles with clonic exacerbations, due to the introduction into the 
system from a wound of the ptomaines of the bacillus tetani. 

What are the causes of tetanus? 

1. Predisposing. Hot climate, exposure to cold and damp, or 
sudden change of temperature, negro race, lacerated and punc- 
tured wounds, burns, frost-bites, all septic wounds. 

2. Exciting. A micro-organism. 



WOUNDS. 53 

What are the symptoms of tetanus? 

A slight stiffness of the muscles of the neck and jaws, with 
increase of pain, and the appearance of a sanious or ichorous dis- 
charge in the wounded part, denote the onset of the disease. 
All the voluntary muscles, including those of respiration, may 
become involved. There is intense precordial pain from tonic 
spasm of the diaphragm, the countenance exhibits a peculiar 
grinning expression (risus sardonicus), and at the slightest irri- 
tation, such as a breath of air, a loud noise, or an attempt to 
swallow, violent spasms occur which may variously contort the 
body. If the spinal muscles are chiefly affected, we have opis- 
thotonos, or arching backward, the body being supported on the 
head and heels. Emprosthotonos may be developed, the body 
being bent forward and rolled up like a ball. More rarely pleu- 
rothotonos, or drawing of the body to one side, is seen. The 
skin is wet, the bowels confined, the temperature about normal ; 
it may rise to 108° or 110° shortly before death. Intellect 
clear. 

What is the prognosis of tetanus ? 

Bad in acute cases ; becomes more favorable if life be pro- 
longed till the twelfth day. Death occurs from spasm of the 
glottis or respiratory muscles, from syncope, from exhaustion. 

What are the diagnostic points of tetanus ? 

The absence of fever from the first, the tonic character of the 
spasm, the early involvement of the neck and jaw, the marked 
convulsive attacks, and the clear mind. 

Give the treatment of tetanus. 

Local. Make the wound aseptic. 

Constitutional. Bromide of potassium up to its constitutional 
effect (40 to 80 grains every two hours), chloral at night to produce 
sleep. Morphia may be given ; it must be pushed to the extreme 
limit of safety. An antitoxine has been advised, consisting of the 
blood serum of animals rendered immune by inoculations. This 
is given hypodermatically. Recently, in some cases antitoxine 
has been injected directly into the frontal lobe of the brain. To 
prevent death from asphyxia, give chloroform during the spasm. 
Stimulants and nourishing diet are indicated from the first. 



54 ESSENTIALS OF SURGERY 



Hydrophobia. 

What is hydrophobia ? 

A disease due to a specific poison introduced into the system 
by the bite of a rabid animal. 

What bites are especially liable to be followed by hydrophobia? 

Those on the face, or involving parts of the body unprotected 
by clothing. 

What is the period of incubation ? 

It varies from six weeks to three months ; it may be a very 
few days, or many years. 

What are the symptoms of hydrophobia ? 

First stage, or stage of melancholia, itching, burning, or inflam- 
mation of the cicatrized wound ; anxiety, melancholia, or change 
of disposition ; slight difficulty in swallowing, or a catch in the 
respiration. After a few days the disease is fully developed. 
The stage of excitement is characterized by clonic convulsions, 
involving especially the muscles of respiration and deglutition ; 
by mental disorder similar to that of delirium tremens, with 
periods of maniacal excitement, and intervals of lucidity. It is 
followed after some days by the stage of exhaustion and paralysis. 
The muscular system is entirely unresponsive, and the dying pa- 
tient lies motionless ; the mind is often clear at this stage. 

How do you treat hydrophobia ? 

At the time the wound is inflicted, cauterize, at once and thor 
oughly, by hot iron, nitric acid, or caustic potash. Suck the wound. 
If the wound has cicatrized when seen, excise the cicatrix. Send 
the patient where he can be inoculated after Pasteur's method 
with attenuated virus. 

When the symptoms are pronounced, morphia, chloral, chloro- 
form to relieve suffering. Pilocarpine gr. £ hypodermically, 
repeated frequently. Hot vapor bath. 



WOUNDS. 55 

Glanders. 

What is glanders? 

An infective disease of horses, dependent on a specific micro- 
organism ; communicable to man through wounds, or the mu- 
cous membrane. In horses it is called glanders when it attacks 
the nasal mucous membrane, farcy when it attacks the lymphatic 
vessels and glands. 

What are the symptoms of glanders ? 

A discharge from the nose, thin, sanious, offensive, purulent, 
with involvement of the submaxillary glands. A pustular erup- 
tion resembling smallpox, involving the skin and the mucous 
membrane of the respiratory and alimentary tracts. Sub-cutane- 
ous nodules, shortly breaking down and forming foul ulcers. 
There is fever, which quickly becomes adynamic, and death 
takes place within a week from septicaemia or pysemia. There is 
a chronic form of glanders with less marked symptoms, and from 
which recovery is possible. 

How do yon treat glanders ? 

Use antiseptic nose washes (boracic acid or weak bichloride 
solution). Open abscesses. Pursue from the first a tonic, stimu- 
lating, and supporting treatment. 



Malignant Pustule. 

What is anthrax ? 

A specific infective disease due to the entrance of a bacillus 
or its spores into the system. Its starting-point is in a scratch 
or abrasion. It is found, in this country, mainly among those 
who handle imported hides or wool. 

What are the symptoms of anthrax ? 

A red, itching pimple, followed shortly by a vesicle attended 
with well-marked, brawny induration. Sloughing begins at once, 
and the anthrax pustule is formed, characterized by a dry, central 
slough, surrounded by a ring of vesicles, peripheral to which there 



56 ESSENTIALS OF SURGERY. 

is an area of redness, induration, and great oedema. The neigh- 
boring lymphatic glands are involved. Fever of an adynamic 
type develops, and the patient commonly perishes of exhaustion 
or syncope. Diagnosis by examining the contents of the vesicle •, 
bacilli from ^g to y^s of an inch in length can be detected by 
low powers of the microscope. 

How do you treat malignant pustule ? 

Freely excise the pustule, and either cauterize the wound with 
caustic potash or carbolic acid, or wash thoroughly and repeatedly 
with 5 per cent, potassium permanganate solution. A stimu- 
lant, tonic, and supporting treatment is indicated constitution- 
ally. 

The Healing of Wounds. 

Describe the process of repair in incised wounds. 

Repair takes place in all wounds by the organization of plastic 
lymph. 

If the wound is an incised one, if its surfaces are accurately 
approximated, if it is not subject to irritation, either mechanical 
or chemical, the exudation takes place in minimum quantity, 
the red blood corpuscles of the blood clot are absorbed ; in 
twenty-four hours the surfaces adhere, and in two or three 
days the thin layer of plastic lymph which binds them together 
is supplied with vessels ; this is called union by adhesion or by 
first intention. Inflammation scarcely passes the first stage ; 
there is simply a little hyperemia, pufliness, and tenderness 
about the lips of the wound. 

If the wound surfaces are not accurately apposed, if they 
are subject to irritation, either mechanical, from improper 
dressing, or chemical, from irritating applications or the pro- 
ducts of germ life, the exudation becomes excessive ; there is 
death of tissue, there is suppuration ; if tension and other 
sources of irritation be removed by free discharge, the gap is 
promptly filled in with organized plastic lymph or granulations, 
and the wound heals by granulation or second intention. 

If healthy granulating surfaces can be brought together and 



WOUNDS. 57 

retained in position, permanent adhesion between them takes 
place at once. This constitutes union by secondary adhesion or 
third intention. 

Primary adhesion or first intention. The prompt union of 
divided surfaces without obvious signs of inflammation. 

Adhesion by granulation or second intention. The union of 
divided surfaces by granulation tissue (organized lymph), at- 
tended with evident inflammatory symptoms. 

Secondary adhesion or third intention. The union of granula- 
ting surfaces. Amputation flaps which fail to unite by primary 
intention heal in this way. 

What circumstances prevent wounds from healing by primary 
intention? 

1. Want of accurate apposition ; from gaping, from extensive 
loss of substance, from retained blood or wound secretions, or 
from foreign body. 

2. Want of proper protection. There may be undue motion of 
the part, it may be subject to direct mechanical or chemical 
violence, it may be exposed to infection from poisonous agents. 

3. Defective nutrition, either local, from bad position or from 
tension, or general from constitutional weakness. 

The Treatment of Wounds. 

What are the general indications in the treatment of wounds? 

1. Arrest hemorrhage. 

2. Cleanse, and remove foreign bodies. 

3. Provide for drainage. 

4. Bring the wounded surfaces in contact, and keep them 
apposed. 

5. Provide for absolute local rest. 

6. Prevent putrefaction. 

Name the varieties of hemorrhage. 

Arterial^ Venous, Capillary. Internal or concealed hemorrhage 
indicates bleeding into one of the cavities of the body. Ex- 
travasation indicates bleeding into the areolar tissue. Further, 
hemorrhage may be primary, intermediate or consecutive, secondary. 



58 ESSENTIALS OF SURGERY. 

What are the characteristics of the different kinds of hemor- 
rhage ? 

Arterial. Bright red blood jets from the wound. Pressure 
on the arterial trunk above checks the bleeding. 

Venous. Dark blood wells from the wound. Pressure on the 
venous trunk below checks the bleeding. 

Capillary. The blood oozes from the surface of the wound, 
and collects as a pool in its deeper parts. 

What are the constitutional effects of hemorrhage? 

A feeble, fluttering, rapid pulse, finally perceptible in the 
large arteries only. A cold, blanched, wet surface, with colorless 
lips, and sighing respiration. ^Nausea. Frequently, uncontrol- 
lable restlessness, a roaring in the ears, darkness before the eyes, 
and horrible sinking sensations. The patient may suddenly 
faint. In syncope the heart's action is so feeble that clotting 
may take place and bleeding be permanently arrested, or, on re- 
action, the clot may be washed away by the returning blood 
current and bleeding continue, to end in a return of syncope, 
in convulsions and death. Or the patient may recover, passing 
into the condition known as hemorrhagic fever, an irritative fever 
characterized by rise of temperature, extreme restlessness, great 
thirst, and a quick jerky pulse. 

A sudden violent hemorrhage is much more liable to produce 
fatal syncope than a slow continuous one. Infants bear the loss 
of blood very badly. 

Describe nature's method of arresting hemorrhage. 

1. Contraction and retraction of the vessels. 

2. Coagulations of the blood aided, after severe bleeding, by 
enfeebled heart action and alteration in the composition of the blood. 

On cutting an artery the muscular fibres of its midddle coat 
contract, narrowing or closing the lumen and drawing the end 
of the vessel from its sheath ; the cut ends also retract from each 
other, owing to the natural elasticity of the artery. Neither con- 
traction nor retraction can take place unless the artery is entirely 
cut across; hence, complete section of a bleeding artery often 
stops the hemorrhage. 



wounds. 59 

Coagulation is excited by the divided vessel wall, the sheath 
of the artery, and the air ; it presently occludes the opening in 
the artery, and also fills with clot the space left vacant in the 
sheath by retraction ; this constitutes external clot. Coagulation 
also extends from the mouth of the vessel backward, forming a 
clot, conical in shape, with its base to the wound, and extend- 
ing as far as the nearest branch ; this constitutes the internal 
clot. 

By continued hemorrhage the blood is made more coagulable ; 
a clot forms too rapidly to be washed away by the feeble arterial 
wave. Arrest of hemorrhage from veins is due to coagulation. 
The permanent arrest of hemorrhage is effected by the exudation 
of plastic lymph, which takes the place of the clot, the subsequent 
organization of this lymph, and the conversion of the occluded 
part of the artery into a fibrous cord. 

What is the constitutional treatment of hemorrhage ? 

The patient should be laid flat on his back ; if the symptoms 
are very severe, elevate the foot of his bed and apply an Esmarch's 
bandage to the legs and arms, thus keeping the blood to the 
nerve centres. Hot bottles may be applied about the body. In 
extreme cases resort to transfusion. Ether Tftxxx., morphia 
gr. |, should be given subcutaneously. Place a mustard plaster 
over the heart. Give injections of hot water and brandy. Hot 
coffee or beef tea in frequently repeated small doses by the mouth, 
if the stomach is retentive. As the patient recovers stop stimu- 
lants. Give milk diet at first, increasing as rapidly as possible. 
Give iron as soon as the stomach will allow of its use. In all 
cases avoid stimulants unless life is directly threatened by cardiac 
failure. The use of stimulants is frequently attended by a re- 
turn of bleeding. 

Describe the methods of transfusion. 

Blood or saline solutions may be used. It must be introduced 
warm (98°-100°), in sufficient quantity to add strength and 
volume to the pulse, and must not contain bubbles of air. Trans- 
fusion may be immediate, the blood being passed directly from 
the vein of the donor to the patient's circulation ; or mediate, the 
blood being first whipped and strained of its fibrin, then injected. 



S 



60 ESSENTIALS OF SURGERY. 

How do you check hemorrhage? 

By 1. Position. 2. Cold. 3. Heat. 4. Pressure. 5. Styp- 
tics. 6. Cautery. 7. Ligation. 8. Torsion. 9. Acupressure. 
10. Forcipressure. 11. Constitutional treatment. 

What position favors the checking of hemorrhage ? 

Elevation of the part and forcible flexion. Flexion bends the 
artery sharply on itself, and is applicable to wounds of the ex- 
tremities. 

Describe the use of cold as a haemostatic. 

Used only to check bleeding from smaller vessels. Causes con- 
traction and coagulation. Ice, ice- water as a fine forcible stream 
directed against the bleeding point, or a spray of ethyl chloride. 

Describe the use of heat as a haemostatic. 

Used to check general oozing from large surfaces. It causes 
contraction and coagulation. Apply in the form of large com- 
presses wrung out in hot (120°-140°) water. 

Describe the use of pressure as a haemostatic. 

A graduated compress and a bandage may be used for the 
permanent arrest of hemorrhage when other means are not avail- 
able, or when several vessels are bleeding and there is a firm 
bone against which to make pressure. Instance, wounds of the 
palm or of the scalp. 

As a temporary means of checking bleeding the finger in the 
wound is most efficient, the hemorrhage from any accessible 
artery can be checked in this way. The tourniquet and Es- 
march's rubber tube are also of temporary service. 

Describe the use of styptics as haemostatics. 

Act by coagulating the blood, they also contract the arteries. 
They must be brought into immediate contact with the bleeding 
vessel. They all interfere with primary union. Use powdered 
alum, antipyrine, tannin, gallic acid, or persulphate of iron ; so- 
lutions of the same drugs, especially hot saturated solutions of 
alum, maybe employed; alcohol, turpentine, chloroform are 
also recommended. Chiefly useful in checking bleeding from 
malignant ulcers or in inaccessible regions. Styptics should be 
employed in conjunction with pressure. 



WOUNDS. 61 

Describe the use of the actual cautery as a haemostatic. 

It coagulates the blood, causes contraction of the muscular coat 
of the artery, and forms an eschar. It should not be heated be- 
yond a dull red. Secondary hemorrhage may occur when the 
eschar separates. Applicable where there is difficulty in placing 
ligatures. Instance, in operation about the bones of the face. 
Paquelin's cautery or the galvano cautery should be used. 

Describe ligation as a means of arresting hemorrhage. 

This is the most important of all haemostatic agents. By the 
pressure of the thread, the middle and internal coats are divided, 
and curl up within the vessel, causing clotting ; this clotting 
extends to the first lateral branch. 

If the artery is ligated in its continuity, a conical clot is formed 
on both the distal and proximal sides of the ligature, with the 
apex in each case pointing away from the thread. 

About the ligature there is deposited a layer of plastic lymph ; 
the internal clot becomes infiltrated with leucocytes and or- 
ganizes ; the ligature, if aseptic, is either absorbed or encysted, 
and the artery is converted into a fibrous cord. If the ligature 
is septic, or subject to irritation, it separates by ulceration; this 
separation may be accompanied by secondary hemorrhage. 

What precautions are observed in applying a ligature? 

It must be aseptic. It should include only the vessel. If ap- 
plied to an artery in its continuity, a healthy part of the vessel 
must be selected ; a square knot should be tied. 

Of what should ligatures be made? 

Catgut, rendered aseptic by carbolic acid, corrosive sublimate, 
boiling in alcohol or cumol, or some other method, and possibly 
hardened by chromicizing ; sterile silk. 

Describe the method of applying torsion as a haemostatic. 

Torsion consists in seizing the artery in torsion forceps, draw- 
ing it from its sheath, and twisting till the inner and middle 
coats give way. 

Describe acupressure. 

This consists in checking hemorrhage by compressing the 



62 



ESSENTIALS OF SURGERY. 



wounded vessel between an acupressure needle and the tissues. 
The methods of accomplishing this are by — 

1. Circumclusion. A pin or needle is thrust through the tissues, 
beneath the artery, and brought out to the surface on the opposite 
side. If necessary a thread can be carried around the two ex- 
tremities of the pin in the form of a figure-of-8. The hare-lip 
suture is really an application of circumclusion. 

2. Torsoclusion. The pin transfixes the tissues parallel to the 
artery, is twisted till it lies at right angles to its former direc- 
tion, is pushed directly across the artery, and plunges into the 
tissues on the opposite side. 

3. Retroclusion. The needle is carried in and out, transfixing 
the tissues on one side of the artery and at right angles to its 
course. The point of the needle is then carried over the artery 
to the opposite side, is plunged directly downwards, is carried 

under the artery and its point makes its 
Fi S- 1 - appearance on the side from which it 

originally started. 

Describe forcipressure. 

Forcipressure consists in seizing the 
end of the bleeding vessel in haemostatic 
forceps, which are allowed to remain in 
place till either the end of the opera- 
tion, or till the forceps are required in 
another place, when they should be 
gently removed. The artery is crushed ; 
the middle and inner coats break as in 
ligation. 

What drugs may be administered by 
the mouth for the arrest of hem- 
orrhage ? 
Opium, ergot, ol. erigeron., acid. 

sulph. aromat, acetate of lead. 

What is primary hemorrhage ? 

Bleeding which occurs immediately, 
Hemostatic forceps. on the infliction of a wound. 




WOUNDS. 63 

What is recurrent hemorrhage? 

Synonyms : Keactionary, consecutive, intermediate. 

Bleeding, which comes on with reaction. It occurs within the 
first twenty-four hours after a wound. 

What are the causes of recurrent hemorrhage ? 

The slipping of a ligature. The displacement of a clot. This 
may occur from the wounded part not being kept at rest, or from 
the increased force of reaction circulation. 

How do you treat recurrent hemorrhage ? 

First elevaze, and apply firm pressure by means of additional 
bandages, covering in the soiled dressings with antiseptic gauze. 
If bleeding still continues, remove the dressing, open the wound, 
clear out the clots, and ligate or secure the bleeding vessel. 

What is secondary hemorrhage? 

Bleeding which comes on between the end of the first day and 
the complete cicatrization of the wound. It is most frequent 
about the time of the separation of ligatures or sloughs. 

What are the causes of secondary hemorrhage ? 

1. Constitutional conditions which interfere with organization, 
or are associated with an overacting heart. Instance, Bright's 
disease, diabetes, haemophilia, traumatic delirium, septicaemia, 
pysemia, and plethora. 

2. Disease of the arterial walls, as found in atheroma, calcare- 
ous degeneration, syphilis, or tuberculosis. 

3. Septic condition of the wound. The ulceration and sloughing 
may involve the arterial walls. 

4. Defect in the ligature or its application. The ligature may 
soften prematurely. It may be septic and cause suppuration. 
It may be badly applied, being too loose, or irregularly knotted, 
or tied too near a collateral branch. 

How do you treat secondary hemorrhage ? 

If from a severed artery, as in a stump, and only a few days 
have elapsed since the infliction of the wound, treat as consecu- 
tive hemorrhage ; that is, try elevation and pressure first, if the 
bleeding be moderate, that failing, or at once, in case of violent 



64 ESSENTIALS OF SURGERY. 

hemorrhage, reopen the wound and secure the vessel. If there 
is much sloughing use the actual cautery. 

Later, when the healing is well advanced, try pressure first, 
then either reopen the wound, or ligate the main artery just 
above. If the bleeding recurs amputate higher up. 

If from an artery tied in its continuity. Pressure by graduated 
compresses and compression of the artery above. If this fails 
open the wound and tie above and below. Should the bleeding still 
persist amputate, if the femoral artery is the one involved, or 
tie above, in the case of other arteries. 

How do you cleanse wounds ? 

Gross foreign particles can be picked out with forceps. Blood 
clots and dust should be washed away by means of a fine stream 
of sterile or antiseptic liquid ; avoid all rough handling or 
rubbing. 

How do you provide for drainage ? 

By means of drainage tubes, which may be made of red rub- 
ber, glass, or decalcified bone ; or by strands of catgut or horse- 
hair. Drainage does not allow the serous exudate to make 
tension in the wound, or to remain as a rich culture fluid for the 
reception of germs. It should be employed in all wounds ex- 
cept those which are superficial, or are placed in very vascular 
regions, as in the face. Drainage tubes are to be removed in 
from 24 to 48 hours. If the wound is very deep and extensive 
take the tubes out gradually. The tube should be carried 
through the protective, should be cut off flush with the surface, 
and should be prevented from slipping into the wound by silver 
wire or a safety pin. 

How do you close wounds ? 

Both edges and surfaces must be approximated. In superficial 
wounds adhesive plaster, isinglass plaster, or gauze collodion 
and iodoform may be used. In deep wounds sutures must be 
employed together with compresses and bandages. 

Of what materials are the ordinary sutures made ? 

Silk, silver wire, catgut, horsehair. 



WOUNDS 



65 



Describe the various kinds of suturing. 

1.. The continuous (glover's). The stitches are made with one 
unbroken thread, carried across the wound in one direction. 

2. The interrupted. Each stitch is carried across the wound 
and tied as inserted. 

Fig. 2. 




Interrupted sutures. 

3. Pin suture (twisted or hare-lip). The apposed margins of 
a wound are transfixed with pins, around the two ends of which 
and across the wound is carried a thread in the form of a fig- 
ure-of-eight. This keeps the surfaces in accurate apposition, 
and checks bleeding (circumclusion). 

4. The quill suture. Threads are passed deeply across the 
wound and looped around quills or sections of catheter, placed 
parallel to the wound and at some little distance from its edges. 

The button or plate suture. "Wire is passed across the very bot- 
tom of the wound, brought out to the surface at some distance from 
its edges, and secured by fastening to leaden plates or buttons. 

The subcuticular suture of Hoisted. In this the suture material 
is passed through the true skin, but not through the epidermis. 

The Lembert and Czerny sutures will be described under 
intestinal wounds. 

"When there is much gaping, or loss of substance, the plate or 
quill sutures are used, they prevent tension in the skin sutures, 
and are termed sutures of relaxation. If the wound is moder- 
ately deep, a number of interrupted sutures are passed across 
5 




66 ESSENTIALS OF SURGERY. 

Fi g« 3 * it to its bottom and brought 

out at some little distance 
from its edges, these are 
termed sutures of approxima- 
tion. The skin is accurately 
joined by closely applied super- 
ficial sutures, either interrupt- 
ed or continuous, called sutures 

Sutures of approximation and coaptation. Oj coaptation. 

Unless there is great ten- 
sion, and reason to fear gaping, remove sutures about the fourth 
day. 

How do you prevent putrefactive or infective processes in the 
wound ? 

By antiseptic treatment and dressing. 

Describe the antiseptic treatment. 

There must be provided basins for the sponges. Shallow trays 
for the instruments. A fountain syringe for irrigation. 

Solutions. Carbolic acid 1 : 20. Bichloride of mercury 1 : 500. 
These solutions can be weakened by the addition of water as 
required. 

Sponges and drainage tubes which have been kept in carbolic 
acid 1 : 30. 

Ligatures and sutures which have been rendered aseptic and 
are kept in absolute alcohol. 

The surgeon prepares himself by scrubbing his arms, hands, 
and nails with a brush, soap, and hot water, puts on his anti- 
septic coat and again washes his hands first in alcohol, then in 
sublimate solution 1 : 1000. Some surgeons wear rubber gloves. 

The patient is prepared by a general hot soap bath, if possible. 
The entire region of the wound of operation is scrubbed with hot 
water and sublimate soap, shaved, washed with alcohol, and 
irrigated with 1 : 500 sublimate solution. 

All portions of the patient's body and the operating table 
near the seat of injury are covered with towels wet in 1 :500 
sublimate solution. Instruments and drainage tubes are placed 



WOUNDS. 



67 



in 1 : 30 carbolic solution. The sponges 
are put in a basin and covered with, bi- 
chloride, of the strength used for irriga- 
ting. The fountain syringe is filled 
with bichloride 1:2000. The dress- 
ings are cut to the proper size, and 
wrapped in bichloride towels. 

During the operation or manipulation, 
irrigate occasionally with the bichloride 
solution, finally flushing out, if the 
wound be large, with a weak solution, 
sterile water or salt solution. Carefully 
guard against instruments, sponges, or 
hands coming in contact with non- 
sterilized surfaces. 

At the termination of the operation, 
see that the hemorrhage is absolutely 
stopped, and that drainage is amply pro- 
vided for. Apply the dressing. 



Fig. 4. 




Sutures. 



Describe the antiseptic dressing. 

Listens dressing. Dust with iodoform. Apply a piece of pro- 
tective (varnished silk), wet in 1 : 40 carbolic, just large enough 
to cover the closed wound. Over the protective, and overlap- 
ping it, place several layers of carbolized gauze, wrung out in 
the 1 :40 solution. Over this deep dressing and overlapping it, 
apply six layers of dry carbolized gauze, a seventh of Mackin- 
tosh (rubber cloth), an eighth of gauze. Over the whole and 
about the edges place antiseptic cotton, and cover in with a car- 
bolized gauze bandage. The protective guards the wound sur- 
faces from the irritation of the strongly carbolized gauze. The 
deep wet dressing disinfects the immediate neighborhood of the 
wound ; it is wet because dry cold gauze may contain septic 
particles of dust. The Mackintosh prevents the discharge from 
passing through the gauze immediately to the surface. 

The dressing in ordinary use is : 1. Dry iodoform gauze to 
the wound. 2. Covered and overlapped by bichloride gauze, 



68 ESSENTIALS OF SURGERY. 

3. Bichloride cotton overlapping the whole and covered in by a 
gauze bandage. 

When do you change an antiseptic dressing ? 

1. When drainage tubes or non-absorbable sutures are to be 
removed. 

2. When fever, other than that due to reaction, appears. 

3. When there is hemorrhage. 

4. When the wound is healed. 

Wounds. 

What is a wound? 

A solution in the continuity of the tissues, produced by sudden 
force. 

Under what two headings may wounds be classed? 

1. Subcutaneous wounds. There is either no break in the skin 
or an exceedingly small one compared to the extent of the lesion 
beneath. Instance, the wound of tenotomy is said to be subcu- 
taneous. 

2. Open wounds. The break in the surface is, to a certain ex- 
tent, commensurate to the deeper injury. 

What is a contusion ? 

A subcutaneous injury (distinguish from contused wound in 
which there is a break in the surface) occasioned by squeezing 
or crushing the tissues. There is hemorrhage and discoloration, 
at times vesicles and blebs form, and the part may appear gan- 
grenous. The effused blood may form a fluctuating swelling, 
known as hcematoma, or may coagulate, forming a hard swelling, 
termed thrombus. 

How do you treat contusion ? 

By rest, pressure, and the application of evaporating and 
stimulating lotions. 

Name the different kinds of open wounds. 

1. Incised, or clean cut. 2. Lacerated, or torn. 3. Contused, 



WOUKDS. 69 

or bruised. 4. Punctured, or pierced. 5. Gunshot, or lacerated 
and contused. 6. Poisoned. 

Describe incised wounds. 

Cause. Sharp cutting instruments. They bleed freely, gape 
widely, and cause burning pain. 

Treatment. Use all antiseptic precautions. Check hemorrhage 
by cold, forcipressure, and ligation. Bring the surface and edges 
of the wound in most accurate apposition. If tendons, nerves, 
muscles, or bones are severed, their corresponding ends must be 
carefully united by catgut sutures. If the wound is extensive, 
catgut drains may be employed. Absolute rest must be enforced. 
Union, in seven to ten days, by first intention 

Despribe lacerated and contused wounds. 

Caused by machinery, dog-bites, blows with blunt instrument, 
etc. 

Characterized by slight hemorrhage, moderate gaping, dull 
pain, ecchymosis (hemorrhage into the surrounding tissue), and 
shock. 

Treatment. Antiseptic. Thoroughly cleanse, remove dead tis- 
sue, provide for free drainage, making counter openings in depend- 
ent positions, and using full-sized rubber drainage-tubes. Care- 
fully coapt, if it can be done without tension. Apply iodoform 
gauze liberally, bichloride gauze, bichloride cotton, and band- 
ages. Keep the part absolutely at rest. 

Dangerous complications. Shock, extensive inflammation and 
sloughing, secondary hemorrhage, cellulitis, gangrene, tetanus. 

Describe punctured wounds. 

Caused by pointed instruments ; depth is their greatest meas- 
urement. Usually associated with contusion. 

Dangers. Wounds of deep structures, hemorrhage, the car- 
rying in of septic substances, retention of discharge. 

Treatment. Remove the vulnerating body, check bleeding, 
thoroughly disinfect the accessible portion of the wound, put in 
a drainage-tube, apply an antiseptic dressing, and put the part 
at rest. On the first sign of inflammation (pain and fever) re- 



70 ESSENTIALS OF SURGERY. 

move the dressings, and lay the wound open to its very bottom ; 
disinfect, drain, and reapply the antiseptic dressing. 

Describe gunshot wounds. 

Caused by missiles, either round (buck-shot, bird-shot) or coni- 
cal (pistol and rifle balls). The wound of entrance is smaller 
than the wound of exit, and is slower in healing. One bullet 
may cause multiple wounds, depending upon the position of 
the wounded man and the direction from which the missile 
comes. Two bullets may form but one wound of entrance. One 
bullet may form several wounds of exit by being split; the 
wound of entrance may also be the wound of exit, as when a 
ball passes completely around the head, beneath the skin. 

Balls may be deflected by tendons, bones, or even bloodves- 
sels. Devitalization of tissue is proportionate to the velocity of 
the ball ; hence is greatest at the wound of entrance. The mod- 
ern rifle propels a ball with great velocity, and the bullet is 
coated with a hard metal. 

The immediate effect of gunshot wounds is hemorrhage, pain, 
and shock. There may be no pain ; excessive hemorrhage oc- 
curs only when large vessels have been wounded ; shock may 
be delayed. The secondary effect of gunshot wounds is inflamma- 
tion, sloughing, hemorrhage, with the complications incident to 
contused and lacerated wounds (tetanus, gangrene, cellulitis, 
and blood poison). 

How do you treat gunshot wounds ? 

On the field. Check hemorrhage by position, pressure, or the 
tourniquet. Apply an antiseptic pad to the surface wounds. Im- 
mobilize. If no septic matter has been carried in by the missile, 
or the surgeon's probe or finger, the wound is practically rendered 
subcutaneous by this treatment, and can be allowed to heal as 
such, no effort being made to find the ball. 

In the hospital. Under all antiseptic precautions, remove the 
antiseptic pad, thoroughly clean the opening of the wound and 
the skin surface about it. Keapply an antiseptic dressing and 
immobilize. Do not probe. If inflammatory fever appears, or 
if the original wound was so extensive as to preclude the idea 



WOUNDS. 71 

of primary occlusion, do a formal antiseptic operation. Freely lay 
open the wound tract, remove foreign bodies, devitalized tissues, 
or loose fragments of bone, explore and irrigate every recess of 
the wound, pack with iodoform gauze, insert sutures for the 
purpose of approximating the parts, but do not tie them, dress 
antiseptically. In one or two days remove the dressing and 
iodoform packing. If the wound is aseptic, close by knotting the 
sutures. If the wound is not aseptic, irrigate and renew the 
packing, or supply free drainage, dressing daily till the granula- 
tions become healthy. An aseptic bullet is readily encysted. 
Should it subsequently give trouble, its removal is much safer 
after the wound has healed. 

Nelaton's probe, tipped with unglazed porcelain, which is 
marked by contact with lead, and long-bladed bullet forceps, 
may be useful in locating and extracting a bullet. The Nela- 
ton probe will not detect a modern bullet with a hard metal 
jacket. A bullet may be located by a telephonic probe, an in- 
duction balance, or an #-ray apparatus. 

"What gunshot wounds require amputation ? 

1. Wounds which comminute the bone and injure or destroy 
the main vessels of a limb. 2. Wounds which destroy a large 
portion of the limb or carry away a part of it. 3. Wounds 
complicated by osteomyelitis, intractable secondary hemor- 
rhage, or spreading gangrene. 

What injuries are classed as poisoned wounds ? 

1. Dissecting wounds. 2. Stings of insects. 3. Wounds in« 
flicted by arachnids and reptiles. 4. Wounds infected from 
diseased animals. 

Describe the dissecting wound. 

It appears more frequently where fresh bodies or arsenical 
injections are dissected. It is due to inoculation with infective 
micro-organisms ; these are destroyed by advanced putrefaction, 
hence the most offensive bodies may be the least dangerous. Its 
virulence depends upon the strength of the original virus and 
the constitutional vigor of the patient infected. 

Symptoms. Within twenty-four hours of the infliction of a 
scratch or cut, there is an itching, then a burning pain ; a vesicle is 



72 ESSENTIALS OF SURGERY. 

formed which breaks, disclosing an indurated ulcer. There may 
be a stop at this stage, or the inflammation may extend ; the 
lymphatic vessel and axillary glands become involved, and may 
suppurate freely. The constitutional symptoms are well marked. 
The patient may reach this stage and rapidly recover, or the 
disease may make steady progress, suppuration attacking the 
neck and thorax, cellulitis involving the arm, the symptoms be- 
coming markedly adynamic, and the patient perishing of septi- 
caemia or pyaemia. 

How do you treat dissecting wounds ? 

Immediately, at the time of infliction, encourage bleeding by 
tying a ligature about the part. Suck the wound and press the 
blood from it ; apply carbolic acid or sulphate of zinc, dust with 
iodoform, and cover with a light antiseptic dressing. 

If an infective inflammation appears, freely incise, curette the 
indurated tissue, pack with iodoform gauze and dress antisepti- 
cally, applying a splint. Open abscesses promptly. Make mul- 
tiple incisions for cellulitis. 

Clear the bowels, give stimulants, tonics, and nutritious diet. 

For pain, apply locally, chloral gr. xx. to the ounce of water. 

A circular blister about the arm may limit the extension of 
lymphangitis. 

There is always marked constitutional involvement in these 
wounds. There is fever and exhaustion, loss of sleep from pain, 
and the rapid development of an adynamic condition. Treat 
by anodynes, stimulants, full diet, tonics. 

(For Anthrax, Glanders, Hydrophobia, see pp. 54, 55.) 

How do you treat stings of insects and spider bites ? 

Locally. Ammonia. 

Systemically. Stimulants if necessary, ammonia or brandy. 

What are the symptoms of rattlesnake poisoning ? 

Kapid and extensive swelling, discoloration, and disintegra- 
tion. Profound systemic depression. 

How do you treat rattlesnake bites? 

1. Put a tight ligature about the part above the wound. 

2. Excise, and subsequently cauterize the wound area. 

3. Encourage bleeding by suction. 



WOUNDS. 73 

4. Administer alcohol to the point of intoxication, and give 
strychnine hypodermatically. 

5. Release the ligature for a few seconds at a time, tightening 
again till each small dose of poison thus admitted to the system 
is eliminated. This is termed the intermittent ligature. 

Injections of permanganate of potassium in and about the 
wound (10 per cent.) are said to be efficient. If collapse threat- 
ens, ammonia must be given hypodermatically. An antivenene 
serum has been advised. 



Wounds of Arteries. 

Describe wounds of the arteries. 

1. Non-penetrating. The outer coat or coats only are in- 
volved. The artery may subsequently ulcerate and give way, 
causing extravasation, or may cicatrize and gradually yield, 
forming true circumscribed traumatic aneurism. 

2. Penetrating. The artery is laid open. It may be partially 
cut across, when there will be free and continuous bleeding, or 
completely cut across, when contraction and retraction favor co- 
agulation. 

How do you treat wounded arteries? 

Ligation in the case of large and accessible arteries ; forcipres- 
sure, acupressure, or the actual cautery under other circum- 
stances. When the artery is partially divided, complete the 
division. In some cases of partial division it is possible to 
suture the vessel with fine silk. 

What rules must be observed in applying the ligature to a 
wounded artery ? 

Tie in the wound. Tie both ends of the wounded vessel. Do not 
search for the arterial wound unless there is actual bleeding at the 
time of search. While operating, check further bleeding by 
pressure, or by the finger in the wound. 

How do you, treat gangrene appearing after ligation of a 
wounded artery ? 

If rapidly progressive, amputate at once. If slow in progress, 
wait for the line of demarcation. 



74 ESSENTIALS OF SURGERY. 

Describe traumatic aneurisms. 

1. Diffuse traumatic aneurism. This is simply a collection of 
arterial blood, in the tissues of a part, which communicates with 
the blood stream in the interior of the artery, and is limited by 
peripheral coagulation. 

2. Circumscribed traumatic aneurism. This is blood in the tis- 
sues, communicating with the arterial current, and provided 
with a sac formed by the condensation of the surrounding cellu- 
lar tissues. The circumscribed traumatic aneurism may be 
formed by a protrusion of the inner coat through a laceration 
of the outer, in which case it is called hernial; or by the yield- 
ing of a cicatrix of the arterial coat, when it is called true circum- 
scribed traumatic aneurism. 

Symptoms as for aneurism, except in the case of diffuse trau- 
matic aneurism, when a spreading tumor, in which thrill and 
bruit can be detected, and feeble or absent circulation of the 
part below, will indicate the nature of the affection. 

How do you treat traumatic aneurism ? 

Ligate just above, or, if the aneurism threatens to burst, open 
the sac and tie above and below. 

Describe an arterio-venous aneurism. 

Definition. An abnormal communication between an artery 
and a vein. 

Cause. A wound involving both vessels. 

Varieties : 1. Aneurismal varix. The artery and vein commu- 
nicate directly. The vein is dilated by the arterial beat, form- 
ing a fusiform swelling. 

2. Varicose aneurism. The artery and vein communicate by 
means of an intermediate sac. 

Symptoms. A tumor, characterized by a jarring pulse, and a 
rough buzzing bruit. The artery is large above and small be- 
low. The vein is large above and pulsates. 

Treatment. Pressure on the tumor by means of an elastic 
bandage. Ligation of the artery above and below. When pres- 
sure fails to control the bleeding from the vein, it must be liga- 
tured also. 



WOUNDS. 75 

What are the dangers in wounds of veins ? 

1. Hemorrhage. Control by pressure or ligation. 

2. Blood poisoning from septic thrombosis. Prevent by keep- 
ing the wound aseptic. 

3. Entrance of air. Characterized by a hissing sound during 
inspiration, by the escape of frothy blood during expiration, by 
a churning sound heard on ausculting the heart, and by prompt 
collapse of the patient. Stop the vein wound immediately with 
the finger, or fill the entire wound with water. Ether, brandy, 
or ammonia subcutaneously. 

How are vein- wounds treated? 

In a slight wound of a vein, apply a lateral ligature. In a 
longitudinal wound and in some transverse wounds, suture with 
fine silk. In extensive wounds, ligate with two ligatures and 
divide the vessel between them. 

Wounds of Nerves. 

What are the consequences of wounded nerves ? 

The nerve may be partially or completely divided. If com- 
pletely divided, the entire peripheral part undergoes atrophy 
and degeneration (Wallerian degeneration), the proximate end 
becomes bulbous from proliferation of the fibrous tissue. Should 
union occur the degenerated fibres are regenerated. 

As a result of destroyed innervation there follows : — 

1. Motor and sensory paralysis. 

2. Muscular atrophy and degeneration. 

3. Trophic changes, characterized by the skin becoming glazed, 
smooth, bluish-red, and prone to ulcerate ; the nails becoming 
cracked and deformed ; the hair falling out ; and rheumatoid 
joint affection. 

How do you treat wounded nerves ? 

If recent, suture together with fine chromicized catgut passed 
through the sheath of the nerve. If old, free from all cicatricial 
adhesions, resect the bulbous proximal extremity, freshen the 
distal extremity, and suture as before. 



76 



ESSENTIALS OF SURGERY. 



Head Injuries. 

Give the surgical anatomy of the scalp. 

Layers. Skin, superficial fascia, aponeurosis of the occipito- 
frontal, subaponeurotic fascia, pericranium. 

Superficial fascia binds the skin firmly to the aponeurosis. It 
is made up of intersecting, non-elastic bands of connective 
tissue, containing in its meshes globules of fat ; it is very vas^ 
cular, and freely supplied with nerves. 

Fig. 5. 




Layers of the scalp. 

Aponeurosis. Covers the vault of the skull, is attached to 
the superior curved line and the mastoid process ; is blended in 
front with the pyramidalis nasi, corrugator supercilii, and 
orbicularis palpebrarum, and is continued laterally to the 
zygoma by laminated layers of areolar tissue. 

Subaponeurotic fascia. Is made of delicate, elastic, con- 
nective-tissue fibres containing no fat ; loose in texture, and 
allowing free motion on the part of the aponeurosis. Blood 
supply limited. 

Arteries of the scalp are from the temporal, occipital, auricular, 
supraorbital, and frontal. Certain branches strike deep and 
supply the periosteum. 

Veins of the scalp intercommunicate with those of the peri- 
cranium, the diploe,the meninges, the sinuses. 

What is the surgical bearing of these facts ? 

1. From the vascularity of the superficial fascia extensive in- 
jury can be quickly repaired. 

2. From its lack of elasticity no tension can be made in 
uniting wounds. There is little gaping unless the aponeurosis 
is cut. 



WOUNDS. 77 

3. From its denseness of structure, effusion, or suppuration 
will probably be circumscribed, and movable only to the extent 
that the aponeurosis can be moved. 

4. In the subaponeurotic fascia effusion or suppuration will 
probably not be circumscribed, from the looseness of structure, 
and will appear as a fluctuating swelling about the ears or the 
root of the nose, from which position it can be moved to the 
various dependent parts of the aponeurotic attachment. 

5. The arrangement of the vessels allows the scalp to be 
entirely detached from the pericranium without loss of vitality. 

6. It also allows of the direct extension of septic processes 
into the diploe and the interior of the skull. 

7. Swellings beneath the pericranium are bounded by the 
sutures and are immovable. 

Describe contusion of the scalp. 

Swelling very rapid. On palpation a soft yielding centre (fluid 
blood), and hard, distinctly outlined edges (fat and coagulum). 

How do you diagnose contusion from depressed fracture ? 

The hard margins about the apparently depressed central 
area are raised from the bone. By firm pressure with the nail 
the clot may be pushed aside, and the bone felt through it. 

In case of fracture, the finger passes directly from the surf ace 
of the skull into a depression, without first surmounting a ridge. 

Where may the effusion due to contusion take place ? 

The blood may be effused in the superficial fascia, beneath the 
aponeurosis and beneath the pericranium. When in the latter 
position it may ossify. 

How do you treat contusions of the scalp? 

Ice-bag till swelling ceases to increase. Evaporating and 
stimulating lotions, moderate pressure. Aspirate a persistent 
hematoma. If suppuration occurs, incise freely. 

How do you treat wounds of the scalp ? 

Carefully shave, wash, and disinfect the region of the wound. 
Remove all foreign matter, and check hemorrhage. If the wound 
is very extensive, drain by strands of horsehair or catgut. Su- 



78 ESSENTIALS OF SURGERY. 

ture, making accurate apposition, apply iodoform, protective, 
wet bichloride gauze, dry bichloride gauze, bichloride cotton, and 
a firm bandage. 

Describe contusions of the cranial bones. 

Contusions may cause — 

1. An inflammation of the pericranium, or periostitis, which 
may terminate in resolution, chronic periostitis, or suppuration, 
involving the neighboring bone, and terminating in caries or ne- 
crosis. 

2. The inflammation may extend to the diploe', causing septic 
osteophlebitis, with septicaemia or pyaemia. 

3. The inflammation may extend to the intracranial struc- 
tures, causing supra- or subdural suppuration. 

4. The inflammation may terminate in chronic osteitis and 
pachymeningitis, causing thickening. 

What symptoms aid the surgeon in determining the character 
and seat of inflammatory action ? 

1. Pus beneath the pericranium, or simple necrosis. Chill and 
fever, moderate in severity, local oedema, tenderness, and deep 
fluctuation. Detection of the diseased bone when the abscess is 
opened. 

2. Pus in the diploe. Chill, high fever, local signs of suppura- 
tion, general symptoms of pyaemia or septicaemia. 

Intracranial extension. High fever, headache, vomiting, mono- 
plegia or hemiplegia, delirium or stupor. 

PotVs puffy tumor, a circumscribed superficial swelling over 
the affected area, sometimes accompanies supradural suppura- 
tion. 

How do you treat contusions of the cranial bones ? 

Open the bowels freely, keep the patient in bed and absolutely 
quiet, give liquid diet, and apply cold to the head. If there is a 
wound, rigid antisepsis must be observed. Should symptoms 
point to subpericranial suppuration, open freely. Deeper suppu- 
ration should at once be exposed by the trephine. 

Classify fractures of the skull. 
A. Fractures of the vault. B. Fractures of the base. 
1. Partial, involving the inner or the outer table. 



WOUNDS. 79 

2. Complete, involving the entire thickness of the skull. The 
inner table is usually damaged more extensively than the outer. 
Of the complete fractures we have— 

1. Fissured, taking the form of a simple crack. 

2. Stellate or radiate, appearing as several fissures radiating in 
different directions. 

3. Comminuted. The bone is broken into several pieces. 

4. Depressed. The bone is pressed in upon the brain. 

5. Punctured or pierced. This is usually accompanied by con- 
siderable comminution of the inner table. 

Any of these fractures may be simple (no external wound) or 
compound (external wound communicating with the break). 

What causes fractures of the vault of the skull ? 

Sudden concentrated force, as the blow of a hammer. 

How do you diagnose fractures of the vault of the skull ? 

Simple fractures without displacement (fissured, stellate) can 
only be inferred from accompanying symptoms. 

Simple fractures with displacemevit can frequently, but not al- 
ways, be detected by careful examination of the surface. There 
is usually depression, and the abrupt bone edges may be felt. 
Symptoms of compression are commonly present. 

Compound fractures can be diagnosed by inspection and palpa- 
tion through the wound. There is frequently free bleeding, and 
there may be escape of cerebrospinal fluid. 

How do you treat fractures of the vault? 

Simple fracture without depression. 

Place the patient in a quiet, darkened room, clear the bowels 
with calomel, cut the hair closely, and apply an ice-bag; give a 
light milk diet (Oij daily). 

Simple fractures with slight depression, but without signs of com- 
pression are treated as above unless symptoms arise. 

In simple fracture with marked depression, trephine, even if 
there are no symptoms. This is done to prevent trouble in the 
future (preventive trephining). 

Compound fractures and punctured fractures. Always trephine. 
Trephine to asepticize, and to elevate if there is depression. 
Thorough asepsis makes the operation practically safe, Pun(> 



80 ESSENTIALS OF SURGERY. 

tures through the supraorbital plate or the nose do not in them- 
selves call for trephining, though the operation should be done 
if unfavorable symptoms subsequently appear. 

What is the cause of fractures at the base of the skull? 

Direct force. Punctures. Driving of a condyle through the 
glenoid fossa by a blow upon the chin, or shattering the cribri- 
form plate of the ethmoid by a blow on the nose. 

Indirect force. 1. Falls upon the buttocks or feet drive the spine 
against the occipital condyles. 

2. Falls upon the cranial vault drive the occipital condyles 
against the spine. If the head is flexed the force is carried back- 
ward, and is exerted on the posterior cerebral fossa. If the head 
is extended, the force is carried forward, and is exerted on the 
anterior or middle cerebral fossa. 

3. Conduction and amplification of vibrations. The force is 
powerful and diffused. If applied to the frontal region, there is 
usually fracture of the anterior cerebral fossa. The middle 
cerebral fossa is fractured by such force applied to the temporo- 
parietal region. The posterior cerebral fossa by force applied to 
the occipital region. 

What are the symptoms of fracture of the anterior cerebral 
fossa ? 

Free and continuous bleeding from the nose. Subconjunctival 
effusion with palpebral ecchymosis, involving the lower eyelid 
particularly. Escape of watery fluid (cerebro-spinal fluid) from 
the nose. Paralysis of the olfactory, optic, or oculo-motor 
nerves. Concussion or compression. 

The blood and cerebro-spinal fluid may pass back into the 
pharynx, which should always be examined in these injuries. 

What symptoms denote fracture of the middle cerebral fossa ? 

Free continued bleeding from the ear, followed by escape of 
cerebro-spinal fluid, increased in quantity by firm pressure on 
the jugular veins. 

Paralysis of the auditory and facial nerves, usually coming on 
some days after the injury. If the membrana tympani is not 
ruptured, the blood and cerebro-spinal fluid will escape into the 
pharynx by way of the Eustachian tube. 



WOUNDS. 81 

What symptoms characterize fractures of the posterior cerebral 
fossa ? 

Examination through the pharynx may show depression or 
comminution. Severe pharyngeal hemorrhage. Ecchymosis in 
the line of the posterior auricular artery (Battle's sign). 

When the neck is not involved in the injury late discoloration 
is a valuable sign of fracture at the base (middle or posterior 
fossa). 

How do you treat fractures of the base ? 

Since these fractures are usually fissured, they, in themselves, 
rarely require treatment. The gravity of fractures of the base 
depends almost entirely upon the concomitant injury to the 
brain or its bloodvessels, and the treatment must be directed to 
the prevention of encephalitis which is liable to develop after 
these injuries. 

Keep the patient absolutely quiet. Elevate the head and ap- 
ply an ice-bag to it. Control restlessness by bromide of potas- 
sium or morphia. Give water only, for 48 hours, then a light 
liquid diet. Mercurials may be used. 

When the cerebro-spinal fluid escapes externally, the fracture 
is, of course, compound, and the channel of escape must, if pos- 
sible, be antiseptically cleansed and occluded. 

Injuries of the Meninges and Brain. 

In what regions may intracranial blood extravasations take 
place ? 

1. Between the dura mater and the skull. 

2. In the cavity of the arachnoid. 

3. In the meshes of the pia mater (on the brain surface). 

4. In the cerebral substance. 

5. In the ventricles. 

What are the sources of extravasation between the dura mater 
and the skull ? 

1. The small vessels passing from the dura to the bone. The 
hemorrhage is slight in amount. 

2. The middle meningeal artery. The usual source of exten- 
sive bleeding. 



82 ESSENTIALS OF SURGERY. 

3. The venous sinuses. Rarely a source of bleeding. 

What symptoms denote extravasation of blood between the dura 
mater and the skull ? 

Symptoms of compression coming on after an interval of im- 
munity. 

Immediately after an injury the patient suffers from concussion 
and shock ; he reacts and recovers from this condition shortly to 
exhibit symptoms of compression, characterized by : 1. Spasm 
followed by paralysis, affecting the face, arm, or one side of the 
body, and accompanied by a local fall of temperature. 2. 
Coma. 3. Widely dilated pupil of the affected side. 

How do you treat hemorrhage between the dura and the skull? 

Trephine over the middle meningeal artery (anterior branch). 
The pin of the trephine is placed 1^ inches behind the external 
angular process of the frontal bone, and the same distance above 
the most prominent part of the zygoma. Clear away the clot, 
close the artery by means of ligatures, a plug of wax or catgut, 
or the touch of a hot needle. If the trephine opening does not 
expose the bleeding point, remove the bone along the course of 
the artery till the source of hemorrhage is found. If no hem- 
orrhage is found, but the symptoms are positive, trephine over 
the posterior branch of the middle meningeal (just below the 
parietal eminence). 

If no supradural hemorrhage is found, but the dura is bluish, 
projecting, and does not pulsate, there is effusion beneath, which 
must be evacuated by incision. 

If the symptoms do not definitely indicate the probable seat 
and nature of the injury, treat as for all head injuries, i. e. , elevate 
the head, and apply cold to it, clear the bowels, give a very 
restricted fluid diet, use bromides, chloral, morphia, mercury, 
or bleeding as indicated by symptoms. 

What are the symptoms of hemorrhage beneath the dura ? 

Blood in the arachnoid is generally diffused over the whole 
cerebral hemisphere. There may be symptoms of compression, 
or, some time after the injury, irritability of temper, headache, 
or convulsions may develop. There is nothing diagnostic. The 



WOUNDS 



83 



effused blood may become encysted or may organize as a tough 
membrane. 

Blood in the pia mater usually accompanied by cerebral lacera- 
tion. The blood is widely diffused. The symptoms are those 
of the brain injury, or of apoplexy. 

How do you treat subdural extravasations ? 

Expectantly, as for head injuries in general. If the symptoms 
should point to localization of the hemorrhage, trephine. 

Concussion and Contusion. 



Describe concussion of the brain. 

By concussion is meant a simple jarring of the brain without 
attendant lesions. There is, however, always congestion, and, 
commonly, serous or sanguinolent effusion. If concussion is at- 
tended with marked and persistent symptoms, it is probably 
associated with contusion. 

Contusion may be circumscribed or diffused. It may produce 
hemorrhage in mass, or diffuse miliary extravasations. Its effects 
may be found at the point of injury, or on the opposite portion 
of the brain. Laceration frequently accompanies contusion. 
The anterior part of the frontal and temporo-sphenoidal lobes 
are commonly involved. 

What are the symptoms of concussion ? 

Of the slighter form, momentary loss of consciousness, or giddi- 
ness, with pale face and feeble pulse, some mental confusion, 
sweating of the face, nausea, vomiting, and reaction. 

Of the more severe forms (contusion, with congestion, bleeding 
or laceration), prolonged unconsciousness, with feeble, scarcely 
perceptible pulse, shallow breathing, pale, cold surface, subnor- 
mal temperature, muscular relaxation, variable pupils (depend- 
ent on the seat and character of the injury). Restlessness, 
screaming, and local spasm or paralysis may suggest lacera- 
tion. The beginning of reaction is characterized by vomiting. 

After a variable time the patient may pass into the second stage 
of concussion, termed cerebral irritation. 



84 ESSENTIALS OF SURGERY. 

He can be roused with difficulty, but responds angrily, and im- 
mediately lapses into a somnolent condition. 

He lies curled up on his side, with limbs flexed and eyes tightly 
closed. He resents any effort at changing his posture. He may 
be exceedingly restless. 

The pulse is small and feeble, the respirations are quiet, or at 
least are not stertorous. The pupils are contracted. 

As the condition of cerebro-irritation subsides, the third stage 
of concussion, characterized by inflammation, abscess, softening, 
or fatuity, may develop. Later, hereditary or acquired tendency 
to brain disease may appear. 

Concussion and contusion are always attended by shock. 

How do you treat cerebral concussion and contusion ? 

First stage (insensibility and shock). Absolute quiet in a dark- 
ened room. If reaction is slow, encourage by external heat. 
Very rarely should stimulants be given ; if absolutely indicated, 
administer brandy or ammonia hypodermically. On the deve- 
lopment of the second stage (cerebral irritation) apply an ice-bag 
to the raised head, clear the bowels, give water and cracked ice 
for two days, followed by milk and lime-water, in small quanti- 
ties. For restlessness and pain give bromide, chloral, or opium. 
Prevent sequelae by long-continued rest in bed, by very slow re- 
sumption of ordinary duties and responsibilities. 



Compression. 

What are the causes of cerebral compression ? 

1. Depressed bone. 2. Extravasated blood. 3. Pus, or in- 
flammatory products. 4. Foreign bodies. 5. Tumors. 

What are the symptoms of cerebral compression ? 

Unconsciousness, absolute (coma). Bespirations, slow, sterto- 
rous, blowing. Pulse full and slow. Paralysis involving one 
side of the body. Pupils may be unequal. Urine retained, faeces 
passed involuntarily. Decubitus dorsal. 

How do yon determine as to the cause of compression ? 

Symptoms appear immediately when due to depressed fracture 



WOUNDS. 85 

or foreign body ; after some hours, if due to hemorrhage ; after 
some days, if due to inflammation. 

How do you treat compression of the brain? 

Trephine and remove the cause, if it can be located. Under 
other circumstances expectantly, as for head injuries in general. 

How do you distinguish concussion from compression? 

In many cases this cannot be done ; the symptoms of one con- 
dition merging into those of the other. The distinctive symp- 
toms of the two affections are as follows (Agnew) : — 

Concussion. Compression. 

Patient semi-conscious ; special Absolutely unconscious, para- 
senses blunted, not abolished. lyzed, and with abolition of special 

Power of movement not lost. senses. 

Respiration quiet and feeble. Respiration full and noisy. 

Pulse feeble, frequent, and inter- Pulse full, slow, laboring, 
mittent. 

Nausea and vomiting. Neither nausea nor vomiting. 

Pupils generally contracted. Pupils generally dilated, often un- 
equal. 

Subnormal temperature. Temperature about normal. 

Of what significance is the size of the pupil in brain injuries? 

A contracted pupil denotes cerebral irritation (slight injuries 
or effusion). A pupil fixed in wide dilatation denotes abolition of 
cerebral function (large effusions or extensive injury). 



Intracranial Inflammation. 

What are the causes of traumatic intracranial inflammation ? 

Wounds of the scalp, bone, or brain. Fractures or contusions of 
the cranial bones. Concussion, compression, contusion, or lacera- 
tion of the brain. 

Describe traumatic intracranial inflammation. 

There may be either meningitis or encephalitis. More com- 
monly, both meninges and brain are involved (meningo-encepha- 
litis). Should suppuration occur, the pus may be diffused, or may 
form an abscess. The inflammation may be acute or chronic. 



86 ESSENTIALS OF SURGERY. 

Give the symptoms of traumatic intracranial inflammation. 

Pain referred to the seat of injury, fever, intolerance of light 
and sound, vomiting with a clear tongue, contracted pupils, quick, 
full pulse, restlessness, insomnia, and delirium. Later, com- 
pression symptoms develop, and the patient perishes comatose. 
Formation of pus is attended by rigors. 

How can you localize the inflammation ? 

If, in from one to four weeks from the infliction of injury, 
symptoms of encephalitis suddenly develop preceded by head- 
ache, if Pott's puffy tumor of the scalp forms, if there is local 
spasm or paralysis, and the history of a chill, there is probably 
an abscess between the dura and the skull. 

Inflammatory symptoms, appearing about the fourth day after 
a head injury, point to contusion or laceration of the brain sub- 
stance. 

If, after several weeks, there is found optic neuritis, with hebe- 
tude, headache, and involvement of motor areas ; if there has 
been a chill, and symptoms of compression develop suddenly, 
there is probably a cerebral abscess. 

How do you treat traumatic meningoencephalitis ? 

Prevent by quiet, cold to the head, purgation, low diet, and 
absolute asepticity of all head wound. 

Treat, on the earliest symptom, by calomel, bleeding from ex- 
ternal jugular, ice-bag to head, light diet ; opium and bromide 
as required, calomel gr. 3. Dover's powder gr. ij every two 
hours. 

If an abscess can be localized, trephine and evacuate. 

Describe hernia cerebri. 

Definition. A protrusion of brain matter disintegrated by in- 
flammatory action, through an opening in the skull. 

Cause. Wound of the bone and dura mater, attended with 
laceration and bruising of the brain substance. 

Appearance. A blood-stained, fungous mass, projecting from 
the skull opening. 

Prognosis. Usually bad. 



WOUNDS. 87 

Treatment. Remove all irritating causes, such as spiculse of 
bone. Treat in general as for encephalitis. 

Locally, apply antiseptic dressings, with very moderate com- 
pression. Nature sometimes effects a cure by strangulating the 
growth. 

What are the prognosis and treatment of foreign bodies in the 
brain? 

The ultimate prognosis is bad in all cases where the foreign 
body is not removed. The usual foreign body is a bullet. Its 
wound may be perforating or penetrating. 

The perforating wound allows of free drainage, and the foreign 
body has passed out ; hence, if not intrinsically fatal, the prog- 
nosis is comparatively favorable. Trephine, if necessary. 

The penetrating wound should be trephined to remove bone 
spiculee. Explore with a soft rubber catheter. The ball, being 
found, should be removed, either through the wound of entrance, 
or by making a counter trephine opening. Provide abundantly 
for drainage. Absolute asepsis. Treat as for head injuries. 

Cerebral Localization. 

Give the position of the motor areas grouped about the fissure 
of Rolando. 

1. The face. Motor and sensory nerves from lower third of 
the ascending frontal and parietal convolutions, and posterior 
end of the second frontal convolutions. 

2. The arm. Motor and sensory supply from middle third of 
ascending frontal and parietal convolutions. 

3. The leg. Motor and sensory supply from the upper portion 
of the ascending frontal and parietal convolutions, and the 
paracentral lobule. 

4. The tongue. Receives its nerve supply from the posterior 
portion of the third (inferior frontal) convolution of the left side 
in right-handed persons. 

Local spasm and hyperesthesia indicate an irritative lesion 
of a motor area. 



88 ESSENTIALS OF SURGERY. 

Local paralysis and anaesthesia indicate complete suppression 
of function from more extensive injury. 

What symptoms founded on cerebral localization indicate tre- 
phining? 

Hemiplegia, complete or incomplete, with or without hemi- 
spasm, following a blow on the temporo-parietal region, would 
indicate an exploratory operation on the side opposite to that 
of peripheral symptoms. 

Monoplegia or monospasm following an injury to the head in- 
dicates operation. 

Mono-hypercesthesia — anaesthesia or analgesia following an in- 
jury indicates an operation. 

If the peripheral sensory or motor disturbance be on the side 
opposite to that of the lesion, operate at the site of the lesion ; 
if, however, these symptoms are on the same side, exploratory 
operation would be indicated on the opposite side of the head. 

What symptoms contraindicate operation ? 

Lesions of the base of the brain as indicated by paralysis of 
cranial nerves, neuro-retinitis, Cheyne-Stokes respiration. 
Hemiplegia accompanied by anaesthesia. 

How can the position of the Rolandic fissure be indicated upon 
the head ? 

Shave the scalp, draw a vertical line from one external 
auditory meatus to the other (at right angles to the alveolo-con- 
dyloid plane), from the centre of this vertical line (bregma) 
measure directly backward for 5.5 centimetres (5 in women). 
From the external angular process of the frontal bone measure 
7 centimetres horizontally backward and 3 centimetres vertically 
upward ; a line drawn from this point to the point 5.5 centi- 
metres posterior to the bregma will indicate the fissure of 
Kolando. For general hemiplegia trephine over the centre of 
the line. In other cases over the portion chiefly involved. 

Sensory disturbances of the arm or leg would indicate that 
the lesion lies somewhat posterior to the fissure of Rolando. 



WOUNDS. 89 

What are the indications for trephining ? 

1. Simple depressed fractures, attended with persistent grave 
symptoms. 

2. Compound depressed fractures. Except in children, when 
the depression is of less serious consequence and often spon- 
taneously corrected. 

3. Punctured fractures. 

4. The presence of a foreign body. 

5. Traumatic osteomyelitis and necrosis. 

6. Localized blood clot between the dura mater and the bone. 

7. Localized intracranial suppuration, with symptoms of com- 
pression or irritation. 

8. Traumatic epilepsy or localized obstinate headache follow- 
ing an injury. 

9. Accessible cerebral tumors. 

Many surgeons advise trephining in all depressed fractures, 
with or without serious symptoms. 

Describe the operation of trephining. 

Prepare the patient the day before the operation, if possible, 
by shaving the scalp and washing with sublimate soap and warm 
water, followed by a cleansing with ether, after which washings 
with the sublimate soap and water must again be repeated. 
Apply, for twenty-four hours, to the entire scalp, gauze saturated 
in 1 : 2000 bichloride solution, covered in with an antiseptic 
dressing. Renew the sublimate and ether washings just before 
the operation, and further cleanse the surface with 1 : 500 bi- 
chloride solution. 

The instruments required are scalpel, haemostatic forceps, 
'periosteal elevators, a conical trephine, a fine probe, a small stiff 
brush, a Hey's saw, bone forceps, curved needles, and catgut. 

The incision. Must be/ree and to the bone, including perios- 
teum. A semicircular flap is raised, the pin of the trephine is 
pressed to the bone, and, by a twisting motion, made to penetrate 
till the teeth grip, when the pin is withdrawn, and the instru- 
ment steadily worked through. Free bleeding indicates when the 
diploe' is reached. (Note that in infancy and old age there is 
practically no diploe. ) The instrument must now be advanced 



90 



ESSENTIALS OF SURGERY. 



with the greatest care. It is removed from time to time, and the 
groove probed to see whether the inner tablet is penetrated at 
any part. When the bone is loosened, it is removed by means 
of sequestrum forceps or an elevator, and wrapped in a warm 
antiseptic towel. The surgeon now endeavors to accomplish 
the specific object for which the skull was opened. Spiculse of 
bone are removed, depressed fractures are elevated, bleeding 
meningeal arteries are secured by passing a thread beneath them, 
clots are cleared away. If further exposure is necessary, it can 
be accomplished by dividing the bone by a chisel, bone forceps, 
or, best of all, a circular saw run by a surgical engine. On the 
completion of the operation free drainage is provided for by 
means of catgut strands, the disk of bone is replaced, either entire 
or cut into pieces, the flap is held in place by one or two sutures. 
Iodoform is dusted over the line of incision, a deep dressing of 
iodoform gauze is applied over and about the wound, and the 
dressing completed by bichloride gauze, bichloride cotton, and 
an elastic bichloride bandage. 



Wounds of the Face, 



What rules should be observed in treating wounds of the face ? 

Secure most accurate coaptation. Avoid sutures in superficial 
wounds, closing by means of iodoform, ether, and collodion. In 
wounds involving the cartilages of the nose or ear, pass sutures 
only through the skin. In operations, so place the incision that 
it may correspond with the natural lines of the face. If stitches 
are inserted, remove them in twenty-four hours. 

How do you treat salivary fistula ? 

This is usually caused by a wound of Steno's duct. Treat by 
passing a thread around the duct from the inside of the cheek 
posterior to the external opening. When this thread has ulce- 
rated an opening into the mouth, the external wound will usually 
heal. If not, freshen its edges and suture. 



wounds. 91 



Wounds of the Neck, 

(For the anatomy of the Cervical Triangles, see Ligations. ) 

Describe wounds of the neck. 

These wounds are commonly incised suicidal wounds. They 
extend obliquely from left to right, and from above downward, 
and are deepest at their starting-point. They are most fre- 
quently found in the laryngeal region, particularly over or 
through the thyrohyoid membrane. The carotid arteries are 
rarely injured, the wound being usually placed too high, and the 
larynx and trachea bearing the brunt of the incision. These 
wounds may be penetrating or non-penetrating. 

Wounds above the hyoid bone may divide the tongue, the lingual 
and facial arteries, and the hypoglossal nerve. There is great 
gaping ; frequently escape of food and saliva. 

Wounds through the thyro-hyoid membrane open the pharynx, 
and may involve the epiglottis, the superior thyroid and lingual 
arteries, and the superior laryngeal nerves. 

Wounds through the cartilages may involve the vocal cords and 
the recurrent laryngeal nerve. There is usually but moderate 
bleeding. 

Wounds below the cartilages may involve the superior or inferior 
thyroid arteries, the thyroid and anterior jugular veins, the 
trachea, and even the oesophagus. 

What are the immediate dangers of penetrating neck wounds ? 

1. Hemorrhage, arterial or venous. 

2. Suffocation from the plugging of the air-passages, with either 
blood-clot, the tongue, the epiglottis, or the divided cartilages. 

3. Entrance of air into the veins. 

What are the secondary dangers of penetrating neck wounds ? 

(Edema of larynx, emphysema, bronchitis or broncho-pneu- 
monia, cellulitis, cicatricial contraction and stricture. 

How do you treat penetrating neck wounds ? 

Check bleeding, ligate both ends of every bleeding vessel. The 
common carotid should only be tied for bleeding from its 



92 ESSENTIALS OF SURGERY. 

branches, when it is found impossible to tie the branches. If the 
external carotid is wounded at its origin, tie the common carotid, 
the external carotid, and, to avoid bleeding from collateral circu- 
lation, the internal carotid. 

If the larynx is obstructed by blood-clot, clear by the fingers, 
by suction, or by forcing the air suddenly from the chest. Re- 
move a partially severed portion of the epiglottis. Hold the 
divided tongue forward by a ligature passed through its tip. 

Wounds of the oesophagus should be closed by catgut sutures. 
If the trachea is completely divided across, the two ends may be 
held in apposition by fine catgut sutures passed through the invest- 
ing cellular tissue. The external wound should not be sutured ; 
its surfaces are apposed by raising the head, and supporting it in 
one position by pillows and sand-bags, or by a gutta-percha splint. 

Provision is made for free drainage, and light antiseptic dress- 
ing is applied. If dyspnoea appears, perform tracheotomy lower 
down, or insert a tracheal canula through the wound. Feed by 
the rectum for four days, then by an oesophageal tube, passed 
just beyond the wound. Non-penetrating wounds are treated 
as wounds in any other part of the body. 



Wounds of the Chest. 

Describe non-penetrating wounds of the chest. 

A non-penetrating chest wound is one which does not involve 
the costal pleura. In chest wounds the finger must be used as a 
probe, and great care taken lest a non-penetrating be converted 
into a penetrating wound. Hemorrhage must be absolutely 
checked before closing, and the wound approximated by deep 
sutures passed to its very bottom. Firm pressure is applied over 
the antiseptic dressing, by a bandage carried around the chest. 

These wounds may involve the brachial plexus, the intercostal, 
internal mammary, acromio-thoracic, long thoracic, or axillary 
arteries. Check bleeding by ligature or haemostatic forceps. 

Describe penetrating wounds of the chest. 

The pleura and lung, the pericardium and heart, or the great 
vessels may be wounded. 



WOUNDS. 93 

Injuries of the pleura and lung are characterized by shock, 
dyspnoea, pain, cough, abdominal breathing, expectoration of 
frothy blood-stained mucus, escape through the wound of a bloody 
froth accompanied by a hissing sound (tromatopnoea), emphysema, 
pneumothorax, external bleeding, hemothorax. In case the 
pleura alone is injured there will be no haemoptysis and no 
bloody froth from the wound. 

Prognosis, grave in wounds involving the root of the lung, 
and in gunshot wounds which penetrate but do not perforate. 

Injuries to the pericardium and heart are characterized by great 
shock, hemorrhage, and the subsequent development, if the pa- 
tient lives long enough, of pericarditis. Death in wounds of the 
pericardium occurs from shock, the pressure effect of haemoperi- 
cardium, or from pericarditis. 

What are the complications of penetrating wounds of the chest? 

External bleeding, hemothorax, emphysema, pneumothorax, 
pleurisy, pneumonia, prolapse of lung. 

How do you treat the external bleeding of penetrating chest 
wounds ? 

If from an intercostal artery ligate, or apply haemostatic forceps ; 
this being impossible, dissect off the periosteum from the lower 
part of the rib (carrying the artery with it of course) and tie ; or 
resect a portion of the rib. A ligature may be carried around 
the entire rib. 

If from the internal mammary, ligate in the wound, resecting 
the chondral cartilages if necessary. 

If from the lung, close the external wound, place the patient 
on the injured side, and apply an ice-bag. Internally give 
opium, ergot, gallic acid. If the bleeding continues, producing 
constitutional signs of hemorrhage, and local signs of extensive 
hsemothorax, open again and allow the blood to escape. In 
some cases ribs have been resected, and the bleeding artery in 
the lung ligated or controlled by packing. 

Describe hsemothorax. 

Definition. Bleeding into the pleural sac. 
Usual cause. Wound of the lung, or of an intercostal artery 
by a broken rib, 



94 ESSENTIALS OF SURGERY. 

Symptom?. Those of internal hemorrhage, together with bulg- 
ing of the intercostal spaces, increasing dyspnoea, flatness on 
percussion, and absence of breathing sounds. The symptoms 
appear almost immediately after the injury. Inflammatory 
effusions do not take place till some days later. 

Treatment. As for external bleeding from lungs. Aspirate 
or open if there is threatening dyspnoea. If suppuration takes 
place, open freely and drain. 

Describe pneumothorax. 

Cause. Injury to lung and pleura, usually by a broken rib. 

Symptoms. The lung collapses. Increasing dyspnoea, great 
percussion resonance, amphoric breathing, metallic tinkling, 
bulging of intercostal spaces. 

Treatment. Should dyspnoea become urgent, aspirate. 

Describe emphysema. 

Cause. Wound of the lung and pleura. It may arise after 
wound of the lung alone, in this case extending by way of the 
root to the posterior mediastinum, and from there into the con- 
nective tissue of the neck and arms. 

Symptoms. A diffused, colorless, elastic, puffy swelling, 
crackling on pressure. 

Treatment. A compress and bandage over the wound. Should 
distension become great, puncture. 

How do you treat prolapse of the lung ? 

Return if not adherent. If adhesions have taken place, ligate 
or excise, taking precautions against opening the pleural cavity. 

Describe hernia of the lung. 

Causes. The yielding of a cicatrix. The result of subcutaneous 
wound. Great muscular effort. 

Symptoms. A soft circumscribed tumor, resonant on percus- 
sion, giving a loud respiratory murmur, and crepitating on 
manipulation. 

Treatment. Protective. 

What is concussion of the lung ? 

A condition following traumatism. Characterized by dyspnoea, 
feeble respiratory murmur, and slight dullness on percussion. 
The symptoms pass off after a few hours. 



WOUNDS. 95 

What operations may be done for the evacuation of blood or in- 
flammatory effusion within the chest walls ? 

1. Tapping the pleura. For serous effusion. Thrust an as- 
pirating needle through the sixth intercostal space, in the mid 
axillary line. This operation must be done under antiseptic 
precautions. The skin is drawn down before the puncture is 
made, forming a valvular wound. Dress with iodoform and 
collodion. 

2. Incision and drainage of pleura. For empyema and the re- 
moval of decomposing clots. Operate in the sixth intercostal 
space, in the axillary line, or as low as the eleventh space, in a 
line with the angle of the scapula. Make a careful dissection. 
Excise a portion of the rib if necessary, and insert a drainage 
tube. 

3. Tapping the pericardium. Fourth intercostal space two 
inches to the left of the sternum. 

4. Incision and drainage of pericardium. Beginning one inch 
from sternum, make an incision two inches in length along the 
upper border of the fifth or sixth ribs. Dissect down carefully, 
insert drainage tube after opening. 

5. Pneumotomy. Lung incision for abscess, gangrene, or 
cysts. Open down to the pleura, thrust a trocar and canula into 
the affected area. Enlarge this puncture by dressing forceps. 

Wounds of the Abdomen. 

Describe contusion of the abdomen. 

Contusion may take place with, or without, rupture of the contained 
viscera. 

Contusion without rupture of the contained viscera is character- 
ized by pain, discoloration, swelling, and shock. The rectus 
muscle may be ruptured, or there may be a hematoma formed, 
followed by abscess. 

Treatment. Put the patient to bed, apply heat to the body, 
hot fomentations to the abdomen. Give water and cracked ice 
for twenty-four hours. Treat rupture of the rectus by position. 
Apply cold in case of hematoma. Evacuate abscesses early. 



96 ESSENTIALS OF SURGERY. 

What symptoms denote contusion with laceration of the viscera? 

Great shock, pain, persistence of collapse with signs and symp- 
toms of internal bleeding, in case the solid viscera or a highly- 
vascular portion of the peritoneum is ruptured, symptoms of 
rapidly developing peritonitis in case the hollow viscera are 
ruptured. 

The following signs, if present, are indicative of rupture of 
the individual viscera. 

Liver. Pain in right hypochondrium, increased hepatic dull- 
ness, signs of internal bleeding ; later, bilious vomiting, clay- 
colored stools, sugar in the urine. 

Spleen. Pain in left side, increased splenic dullness. 

Stomach. Intense pain in stomach, hsematemesis, rapid de- 
velopment of general meteorism, tympany over the liver. 

Intestines. Intense radiating pains. Vomiting of stomach 
contents, then bile, finally blood. Bloody stools. Tympanites 
with dullness in the flanks. Percussion resonance over liver. 
Peritonitis. 

Kidneys. Frequent passage of bloody urine, with extravasa- 
tion in the loin. 

In all cases, the portion of the body which received the brunt 
of violence must be considered, in determining what interna) 
organs are probably injured. 

How do you treat abdominal contusion with rupture of con- 
tained viscera ? 

In doubtful cases, after reaction from shock, insist on abso- 
lute rest and give opium. 

If symptoms characteristic of internal hemorrhage, or rupture 
of a hollow viscus, appear, do an exploratory laparotomy. Bleeding 
from the liver or spleen can be checked by iodoform tamponade, 
or by the actual cautery. Torn vessels in the peritoneum can 
be ligated. Rents in the stomach or intestines can be united by 
sutures or brought to the surface. By irrigation, the peritoneal 
cavity can be freed of blood and extra vasated matter. Ruptured 
kidney with lumbar extravasation should be treated by free 
lumbar incision and drainage. 

What are the causes of traumatic peritonitis? 

The bursting of an abscess, or the extravasation of urine, 



WOUNDS. 97 

blood, bile, or the contents of the alimentary canal into the 
peritoneal cavity. 

Termination usually fatal, from collapse or blood poison. 

What are the symptoms of traumatic peritonitis ? 

Severe pain, at first local, then general. 

Extreme tenderness. Dorsal decubitus with legs and thighs 
drawn up. Breathing thoracic. Abdomen distended and tym- 
panitic; later, dull in the flanks from effusion. Obstinate 
vomiting. Complete constipation Small, quick, wiry pulse. Dry 
brown tongue. Temperature 103° to 104°. 

In the septicemic form there may be little pain or tenderness, 
and a normal or even subnormal temperature throughout 

How do you treat traumatic peritonitis? 

Prevent by absolute rest, cracked ice diet, hot fomentations, 
laparotomy. 

Treat, on the development of the first symptom, by a full saline 
purge and turpentine enema. Open and wash out the peritoneal 
cavity with gallons of hot normal salt solution. Insert a glass 
drainage-tube or gauze drainage. Stimulants and nourishment 
in teaspoonful doses. If there is great exhaustion, employ 
saline transfusion into the median basilic vein. 

How do you treat non-penetrating wounds of the abdomen ? 

Check all bleeding. Extensive extravasation may take place 
between the muscular planes if this precaution is not observed. 
Pass sutures to the bottom of the wound, approximating accurately. 
Prevent tension by position. Apply an antiseptic dressing, and a 
binder about the body. 

If signs of inflammation appear, open freely (abdominal ab- 
scesses do not point). Guard against subsequent hernia. 

Describe penetrating wounds of the abdomen. 

These wounds involve the peritoneal cavity. There may be — 

1. Simple penetration without visceral injury or protrusion. 

2. Penetration with visceral injury, but no protrusion. 

3. Penetration with visceral protrusion, but no injury. 

4. Penetration with both protrusion and injury. 

7 



98 ESSENTIALS OF SURGERY. 

How do you treat simple penetrating abdominal wounds ? 

Thoroughly cleanse. Irrigate the abdomen with salt solution. 
Close the wound by sutures passed from within outward, includ- 
ing the peritoneum and the entire thickness of the abdominal 
wall. Apply an antiseptic dressing and a binder about the 
'body, and place the patient in that position which will most 
effectually relax the wounded muscles. Give internally cracked 
ice for two days, then milk in small quantities. Saline purges 
from time to time. If there has been hemorrhage into the 
peritoneal cavity, remove all blood by irrigation and insert a 
glass drainage-tube. 

How do you treat penetrating wounds with visceral injury? 

Enlarge, if necessary, and treat the visceral injury. Check 
bleeding from the liver and spleen by cautery, or iodoform tam- 
pons. Drain small wounds of the kidney. If the organ be ex- 
tensively lacerated, do a nephrectomy. Wounds of the ureter 
require either a nephrectomy, a uretero-ureterostomy, or the 
formation of a urinary fistula by bringing the ureter to the 
surface. Wounds of the stomach or intestine should be 
sutured; if large, the sutured portion may be secured in 
the wound, the latter not being closed immediately (iodoform 
tamponade). Extravasation will then take place externally 
if the sutures yield. Slight punctures are closed by prolapse 
of the mucous membrane, and do not require suturing. 

How do you determine as to the existence of a visceral injury in 
penetrating abdominal wounds ? 

If the wound is large, inspection and palpation may be suffi- 
cient. 

In small wounds intense pain and severe collapse, with or with- 
out escape of faeces, gas, bile, serum, or food, indicate the nature 
of the injury. 

Wounds of the stomach and intestines usually give a clear 
tympanitic percussion note over the liver. 

In case of doubt inject hydrogen gas into the rectum ; if the 
stomach or intestines are wounded, the gas will escape through 
the wound* Where there is no evidence of visceral wound treat 



WOUNDS. 



99 



as penetrating wound, performing an exploratory laparotomy on 
the first sign of internal hemorrhage or traumatic peritonitis. 

How do you suture the intestine ? 

By the Lembert interrupted suture. The threads include only 
the serous and muscular coats of the bowel, are made of sterilized 




Lembert suture. 

China silk, and are placed a twelfth of an inch apart. The 
suture is designed to approximate serous surfaces. It passes in 
and out on one side of the wound, across, and in and out on the 
other side, and is then tied. Cushing's right-angled suture is a 
continued inversion suture, and is often preferred to the inter- 
rupted inversion suture. If the intestine is entirely torn across 
or extensively injured, a portion may be resected, a V-shaped 
piece of mesentery removed, and the gut ends united by first 
bringing the peritoneal coat together by a circle of interrupted 
O* sutures, then invaginating the incision and approximating se- 
6 rous surfaces by Lembert's suture. This constitutes Czerny's 
J suture. In some cases an artificial anus should be made. 

How do you treat penetrating abdominal wounds with protru- 
sion of viscera ? 
Carefully cleanse and return. If intestine is gangrenous, in- 
cise and leave in the wound ; if congested and adherent, free 
from adhesions and return. The abdominal wound may be 
enlarged if necessary. Congested omentum should be ligated, 
removed, and the stump returned. to the .abdominal cavity. ..If 



100 ESSENTIALS OF SURGERY. 

the intestines protrude and are wounded, apply a Lembert suture 
and return, or make an artificial anus. 

In all extensive injuries do not close the abdominal wound ab- 
solutely. Insert sutures, knot them loosely, and pack the wound 
with iodoform gauze. When danger from intra-peritoneal com- 
plications has passed away, approximate the granulating surfaces 
by removing the packing and drawing the sutures tight. The 
wound heals by secondary adhesion (third intention). 

Describe laparotomy. 

Preparation most thoroughly antiseptic. Incision in median 
line. Check all hemorrhage by haemostatic forceps before open- 
ing peritoneum. The latter is nicked, held up by two fingers, 
and divided by scissors. Insert a large flat sponge to catch all 
oozing from wound. Irrigate the abdominal cavity, if necessary, 
with warm distilled water. If there is much shock, use hot water 
(not over 106°). After the completion of the operation dry with 
sponges, inserting glass drainage-tube if there has beea much 
manipulation or hemorrhage ; close. First bring the peritoneum 
together with a line of interrupted catgut sutures ; then insert 
some plate sutures of relaxation, using silk-worm gut. Suture 
together the fibrous investments of the two rectus muscles ; finally 
unite the skin and subcutaneous tissues with interrupted sutures 
of approximation and continuous sutures of coaptation. 

Dust with iodoform, apply a strip of protective, several layers 
of iodoform gauze, a thick investment of bichloride cotton, Mack- 
intosh, and a moderately tight binder. 

Give cracked ice for two days. Stimulants as required. See 
that the bladder is regularly emptied, drawing the water if 
necessary. 

Describe tapping of the abdomen. 

This operation is done for ascites. 

See that the bladder is empty, pass a many-tailed bandage 
about the body, to make pressure, let the patient sit up, leaning 
somewhat forward, make a skin incision in the linea alba, mid- 
way between the umbilicus and pubis, and thrust the trocar and 
canula into the abdomen. To avoid syncope draw off slowly, 



WOUNDS. 



101 



gradually tighten the bandage as the liquid flows away, and let 
the patient lie down. 

Describe rupture of the bladder. 

Cause. A blow or kick when the bladder is full. Fracture 
of the pelvis. Very rarely from simple over-distension. In re- 
tention from stricture the urethra more commonly gives way. 

The rupture is usually vertical. Occurs more commonly in 
the posterior part, when the urine escapes into the peritoneal 
cavity, causing peritonitis. May occur in the anterior part, with 
extravasation into the loose cellular tissue of the pelvis, causing 
cellulitis with secondary peritonitis or septic poisoning. 

What are the symptoms of ruptured bladder ? 

Collapse following an injury to the abdomen or pelvis, with 
absence of urine and presence of blood in the bladder, as demon- 
strated by passing a catheter. If the patient has passed his 
urine immediately before the injury, inject two ounces of warm 
boracic acid solution (4 per cent.) into the bladder ; if there is 
an extensive rent in its walls, the solution will escape and can- 
not again be drawn off by a catheter. A catheter may some- 
times be felt to pass through the rent. Take a Davidson's 
syringe, plug up one end with cotton, and attach the other to a 
catheter which is inserted in the bladder. Pump in filtered 
air. If the bladder distends, it is not ruptured. We can make 
at the course of the air by percussion. 

How do you treat rupture of the bladder ? 

Do a supra-pubic cystotomy. If the rent is extra-peritoneal, 
insert a drainage tube. If the rent is intra-peritoneal, open the 
peritoneal cavity (through the same parietal incision), irrigate 
thoroughly to wash away all urine. Close the rent by the 
Czerny suture, taking particular care to see that no thread 
pierces the mucous membrane. Insert a drainage tube, tampon 
the external wound with iodoform gauze, and let the patient 
insure free drainage by the lateral decubitus. 

These ruptures may be treated by the introduction and reten- 
tion of a soft catheter passed through the urethra. 



102 ESSENTIALS OF SURGERY. 



Burns and Scalds. 

How are burns classified? 

Burns are of six degrees. 

1st Degree. Simple erythema followed by slight desquamation. 
There is no tissue destruction. 

2c?. Degree. Vesication. The superfical layers of the epiderm 
are destroyed. 

3cZ Degree. Destruction of the epiderm and the greater part of 
the true skin. A portion of the papillary layer, and the epithe- 
lium about the hair follicles and sebaceous glands escapes. 
This is of great importance in the subsequent healing, as skin- 
ning starts from these points as islands, and the elements of true 
skin are preserved to an extent. There is scarring, but not 
marked contractions. This is the most painful form of burn, 
from involvement of the nerve-endings. 

4:th Degree. Destruction of the skin and subcutaneous tissue. 
Scarring and contractions. 

5th Degree. The deep fascia Is penetrated and the muscles are 
involved. 

6th Degree. Destruction of the entire part. 

Describe the constitutional effects of severe burns. 

Dependent on the extent of surface involved, and the depth. 
Three stages. 

1. Shock and internal congestion. Most marked in extensive 
burns of the trunk and head. The patient shivers and complains 
of cold. 

2. Beaction and inflammation. Coming on in from one to two 
days. The patient complains of thirst and inflammatory fever. 
Internal congestion may run on to inflammation, causing menin- 
gitis, pleurisy, or peritonitis, according to the seat of the burn 
(head, chest, abdomen). Duodenal ulcer and nephritis are fre- 
quent complications. 

3. Suppuration and exhaustion, setting in on the separation of 
sloughs. The patient often complains of cough and diarrhoea, 



WOUNDS. 



103 



and may now perish from amyloid degeneration, exhaustion, or 
blood poison. 
Great deformity ensues on cicatrization of deep burns. 

What is your prognosis in severe burns ? 

Bad in burns involving one-third the surface, and in extensive 
burns upon the trunk. Fatal cases mostly perish within forty- 
eight hours from shock. 

How do you treat burns ? 

Constitutionally. Treat the shock by external heat, hot bath, 
hypodermics of brandy, ammonia, atropia, and morphia. See 
that there is no retention of urine. "When reaction and inflam- 
mation appear give a saline cathartic, neutral mixture. If 
the kidneys are congested apply dry cups, hot fomentations. 
Give liquid nourishment in small doses frequently repeated. 
Keep up the use of stimulants. Allay thirst by cracked ice. 
During the third stage give tonics and stimulants, push the 
nourishment, and treat diarrhoea by opium and astringents. 

Locally. All burns beyond those of the first degree should be 
washed and dressed under all antiseptic precautions. 

Burns of the second degree. Wash with 1 : 2000 sublimate solu- 
tion, shave the surrounding skin, remove all loosened epithelium, 
wash again with 1 : 2000, using a soft brush or sponge for the in- 
jured surface, complete the cleansing with 1 : 5000 sublimate 
solution, cover with strips of protective wet in 1 : 5000, sprinkle 
iodoform over the protective, apply a thick layer of iodoform 
gauze overlapping the protective, a still larger and thicker layer 
of bichloride gauze, finally bichloride cotton and a bichloride 
bandage. Cure in ten days on removal of the dressing. 

Burns of the third and fourth degrees, if limited in extent, are 
treated as burns of the second degree. Remove dressings when 
they become rank (ten days), thoroughly bathe in 1 : 5000, trim 
away sloughs, re-dress. When sloughs are all removed, and the 
burn converted to a granulating surface, skin graft. 

When the burn is very extensive cleanse, wash, and remove 
loose cuticle as before, liberally sprinkle each region so treated 
with subnitrate of bismuth, cover with a single layer of lint or soft 



104 ESSENTIALS OF SURGERY. 

linen, held in place by one or two adhesive strips. Twice a day 
gently raise the edges of the lint, and sprinkle more bismuth 
wherever the coating has become loosened by discharge. 

Or, puncture vesicles, but do not remove the cuticle, apply lint 
saturated in carron oil (lime-water and linseed oil in equal parts), 
and cover in with waxed paper and a light bandage. Change the 
dressing daily, uncovering a small amount of surface at a time, and 
redressing one part before another is exposed. 

In extensive deep burns the continued warm bath may be em- 
ployed till the sloughs separate. 

Relieve the pain of burns of the first degree by white-lead 
paint. 

Opium is indicated in all stages of severe burns. 



FRACTURES, 



105 



FRACTURES. 

What is a fracture? 

The sudden solution in the continuity of a bone. 

What are the causes of fracture ? 

1. Predisposing. 

a. Local. Function, form, position, disease of the bone. 

b. Constitutional. Includes conditions under which the 

bone becomes fragile, or subject to disease or injury 
— such as age, sex, rickets, locomotor ataxia, and ne- 
crosis. 

2. Exciting. 

a. External violence. 

b. Muscular action. 

What are the varieties of fracture? 

Incomplete, partial, or greenstick. The bone is bent, but not 
entirely broken through. 
Stellate, grooved, and 
fissured fractures are 
also classed as incom- 
plete. 

Complete. The break 
involves the entire thick- 
ness of the bone. 

Simple. Not accompanied by an open wound leading down 
to the break. A single uncomplicated fracture. 

Compound. Accompanied by a wound leading down to the 
break. 

Single. Having but one line of fracture, making in the long 
bones two fragments. 

Multiple. Two or more fractures, the lines of breakage not 
communicating if these fractures are of the same bone. 

Comminuted. The bone is broken into more than two pieces, 
the lines of fracture communicating. 




Greenstick fracture of clavicle. 



106 ESSENTIALS OF SURGERY. 

Impacted. One fragment is driven into the other, and fixed 
in that position. 

Complicated. Accompanied by an injury to some other im- 
portant parts in the same region, as joints, bloodvessels, nerves, 
or muscles. 

Further, fractures about joints are classed as : — 

Intracapsular — within the capsular ligament. 

Extracapsular — without the capsular ligament. 

In young persons epiphyseal separation occurs, especially in 
the humerus, and constitutes epiphyseal fracture. 

In what direction does the line of fracture extend? 

It is generally oblique, but may be trans verse, from direct vio- 

Fig. 8. 




Oblique and transverse fracture of the tibia. 

lence, longitudinal, when force is applied in the direction of the 
long axis of the bone, spiral or stellate. 

What are the symptoms of fracture ? 

1. Deformity or displacement due to 1, the fracturing force ; 
2, the muscular contractility ; 3, the weight of the part. 

2. Abnormal mobility. 

3. Crepitus, or harsh grating, both felt and heard on manipu- 
lation. 

4. Loss of function. 

5. Pain and tenderness, sharp and severe. 

6. Swelling and ecchymosis, the latter appearing in certain 
lines. 

What are the different kinds of displacement ? 

Angular or bending, rotary or twisting, transverse, longitudinal 
or overlapping. 



m. 



FRACTURES. 107 

When have you difficulty in recognizing displacement? 

When but one of two parallel bones is broken, or when the 
short, flat bones are involved. 

Under what circumstances is crepitus absent ? 

In greenstick and impacted fractures ; when the fragments 
overlap considerably or are widely separated ; when soft tissue 
is interposed between the ends of bone. 

In epiphyseal fracture we have moist crepitus only. 

What fractures do not present abnormal mobility ? 

Greenstick and impacted fractures. 

How do you diagnose a fracture ? 

Deformity, unnatural mobility, and crepitus, if elicited, are 
absolutely diagnostic. If great swelling prevents a positive 
diagnosis, treat as a fracture till swelling subsides. The Ront- 
gen rays may clear, up a doubtful diagnosis. 

What is the general treatment of all fractures ? 

.1. Eeduce the fracture. 2. Retain it in position. 3. Treat in- 
flammation and other complications, either constitutional or 
local. 

How do you reduce a fracture ? 

1. By extension or traction, made by the surgeon steadily 
pulling upon the lower fragment. 

2. Counter-extension or fixation of the upper fragment. 

3. Coaptation or adjusting the broken ends of the bone to 
their proper position. 

How do you overcome muscular spasm? 

If muscular spasm interferes with reduction, it must be over- 
come by position, etherization, or tenotomy. 

How do you retain the bones in proper position ? 

By means of splints and bandages. Splints may be made of 
wood, tin, gutta-percha, binders' board, leather, etc. 

Bandages may be made of muslin, linen, or gauze, or may 
have incorporated with them various materials which, harden- 
ing, make a solid and firm dressing, as plaster, silicate of potas- 
sium, gum, etc. 



108 ESSENTIALS OF SURGERY. 

Under what circumstances are the fixed dressings applied? 

Primarily, when there is little swelling, displacement, or dam- 
age to the soft parts. Secondarily, in fractures of the lower ex- 
tremity, after the subsidence of swelling and inflammation. 

What is ambulatory treatment ? 

A method of applying plaster which permits the patient to 
walk about. The dressing extends below the sole of the foot, 
and the weight of the body is caught above the seat of fracture. 

What rules guide you in the application of splints ? 

1. Splints should be well padded. 

2. They should fix the joints above and below the break. 

3. The extremities of the limbs should be left exposed to view 
(fingers and toes). 

Circular compression must be avoided, primary rollers being 
absolutely discarded in fractures of the leg or forearm. Applied 
with great caution in fractures of the thigh or upper arm. 

How often do you re-dress a fracture ? 

The fracture dressing must be inspected daily for one week. 
If too loose or too tight, or if there is evidence of displacement, 
the dressing must be renewed. Otherwise, twice weekly will 
be sufficient. 

What complications may arise, and how should they be treated? 

1. (Edema and swelling often accompanied by blebs. Treat by 
loose bandaging at first, and evaporating lotions ; follow by pres- 
sure. 

2. Ulceration and sloughing of soft tissues. Free ulcerating 
spot from pressure by careful padding of splint. 

3. Muscular spasm. Treat by moderate pressure, morphia 
injections, or tenotomy. 

4. Gangrene. Usually the result of too tight dressing, or lace- 
ration of main artery. Relieve pressure. 

Rarely. Venous thrombosis, embolism, fat embolus — causing 
death by asphyxia. Treatment : cardiac stimulants. 

How do you treat compound fractures? 

If the external wound is small and the fracture not otherwise 



FRACTURES. 109 

complicated, thoroughly cleanse with bichloride 1 : 1000, and 
close with absorbent cotton saturated in a solution of ether, 
iodoform, and collodion, equal parts of each. Splint as usual. 
If inflammatory symptoms arise, or if there be much original 
comminution or laceration of soft parts, pick out loose frag- 
ments, thoroughly cleanse, irrigate with bichloride solution 
1 : 1000, drain, and apply antiseptic dressing, splinting as usual. 
If wound be older than twenty-four hours, wash with 1 : 5 car- 
bolic solution (acid carbol. 1, alcohol 5). 

What complications arise in the treatment of compound 
fractures ? 

Necrosis, osteomyelitis, periostitis, extensive sloughing of soft 
tissues. 

What is the pathology of fracture ? 

There is first free bleeding from the vessels of the injured bone, 
medulla, and surrounding soft parts. This is followed by in- 
flammation with exudation, absorption of blood clot, and deposit 
of plastic lymph about the seat of injury. Organization completes 
the process ; the plastic lymph is converted first into cartilage, 
then into bone. 

What is callus ? 

The plastic lymph which is organized into bone tissue for the 
repair of fractures. 

How is the callus disposed about a fracture? 

A portion is deposited as a fusiform swelling ensheathing the 
two broken bone ends, called ensheathing callus ; a portion fills the 
medullary canal above and below the break acting as a support- 
ing pin, called pin or central callus. A portion is directly be- 
tween the broken surfaces restoring their continuity, called 
intermediate or definitive callus. 

What is meant by temporary and permanent callus ? 

The ensheathing and pin callus is temporary, being absorbed 
when the bone is firmly united by the intermediate or permaneut 
callus. 



110 ESSENTIALS OF SURGERY. 

What period of time is occupied by the various processes neces- 
sary for the repair of fracture ? 

Absorption of clot first week, formation of plastic lymph and 
beginning organization second week, ossification of the callus 4 
to 8 weeks, absorption of temporary callus one year. 

What complications are common to all fractures ? 

Shock. 

Retention of urine, treat by catheter. 

Traumatic delirium, especially in drunkards — sedatives, 
stimulants. 
Hypostatic congestion of lungs. 

What compound fractures require amputation? 

Compound fractures associated with — 

1. Very extensive laceration of soft parts. 

2. Great destruction of bone substance. 

3. Injury to the main artery of leg or thigh (femoral or post- 
tibial). 

4. Injury to knee or ankle, if extensive. 

Define delayed union and non-union. 

Union is delayed when fractures are not firmly joined by callus 
in 4 to 6 weeks. 

We have non-union or ununited fracture when the continuity 
of the bone is not restored after twelve weeks. 

What are the causes of delayed union and non-union? 

1. Constitutional include all conditions depressing to health 
and nutrition, as acute fevers, syphilis, phthisis, scurvy, ne- 
phritis, etc. 

2. Local, a. Undue mobility of fragments often from improper 
splinting or meddlesome interference. 

I. Separation of fragments, by muscular action, or by interpo- 
sition of soft parts or necrosed bone, 
c. Interference with blood supply, as in intracapsular fracture. 

How do you treat non-union ? 

Treat constitutional conditions. 



FRACTURES. Ill 

Locally the means adopted would be in the order given below, 
one failing the next should be tried. The object of all these 
methods is to set up an acute aseptic inflammation, which shall 
provide sufficient exudation for the formation of healthy callus. 

1. Absolute fixation 7 careful dressing, plaster bandage. 

2. Friction. Rub ends of bone together either manually or by 
getting patient up and allowing some use, the fragments being 
held in apposition by fixed plaster bandage or apparatus. 

3. Brill fragments subcutaneously to excite inflammation and 
deposition of plastic lymph ; treat subsequently by absolute fix- 
ation. 

4. Drill and pin fragments together leaving the pin in place. 

5. Besection of the ends of the bones, joining the fresh surfaces 
by silver wire or bone-clamps. Drain thoroughly and close the 
wound. Secure fixation by careful splinting. 

Name the forms of non-union. 

1. No union whatever between the fragments. 

2. Ligamentous union. 

3. False joint. 

What is vicious union ? 

Union accompanied either by great deformity, or by the bind- 
ing together of bones which should move on each other, as the 
radius and ulna. 

How do you treat vicious union ? 

If recent, restore immediately by force, or by splints and pres- 
sure. If firm union has taken place, or phe fracture is not 
amenable to other treatment, the bone should be broken again, 
properly set, and fixed in position. Deformity from exuberant 
callus gradually disappears. Should it persist, and should 
pressure symptoms arise, callus must be cut away. 

How do you treat an injury which you suspect may be a frac- 
ture? 

Treat as a fracture, subsidence of swelling will clear the diag- 
nosis, 



112 ESSENTIALS OF SURGERY. 

Under what circumstances do you use anaesthetics in the diag- 
nosis and treatment of fracture? 

1. In case of difficulty or doubt. 

2. In complications requiring prolonged Or painful manipu- 
lations. 

3. Where reduction is not readily effected. 

How do you treat the swelling and ecchymosis common to all 
fractures ? 

Evaporating lotions for two or three days, followed by care- 
fully guarded pressure. Four ounces of alcohol and four drachms 
of ammonium muriate, two ounces of the solution of acetate of 
lead, or eight ounces of laudanum, to the pint of water. Apply 
on lint which must not be covered with oiled silk, but kept con- 
stantly wet by the solution. 

What is the cause of the late discoloration in fractures? 

The effused blood gradually works its way to the surface, be- 
tween layers of fascia, in the path of least resistance ; the disin- 
tegration of the red corpuscles causes the ecchymosis or discolo- 
ration. 

What do you mean by an ambulatory dressing? 

A dressing of splints, or preferably of plaster, so applied to a 
fractured lower extremity as to permit the patient to move 
about during treatment. 

Special Fractures. 

Describe fractures of the nasal bone. 

Cause. Direct violence. 

Signs. Displacement, backward or lateral. Crepitus. Un- 
natural mobility. Deformity. Very rapid swelling. Free 
bleeding. 

How may this fracture be complicated? 

1. Profuse hemorrhage. 

2. Emphysema of surrounding soft parts. 

3. Deflection or fracture of septum nasi. 

4. Injury to base of brain through the perpendicular plate of 
ethmoid. 



FRACTURES. 113 

Give the treatment of fracture of the nasal bone. 

Beduce at once by pressure exerted by a director or closed 
haemostatic forceps passed into the nostril. Retain in place, if 
necessary, by packing the nostrils with iodoform gauze or an 
inflatable rubber bag, the respiratory tract being kept open by 
a rubber tube. If there is much comminution and these means 
fail, fasten thefragments together withpivis, passed from the outside, 
taking in the periosteum (Mason's pins). Inspect the nostrils 
for deflection of septum, which must always be replaced. 

Check hemorrhage by heat, cold, astringents, or packing. 

Treat swelling by evaporating lotions. 

Alicays reduce thoroughly. 

Describe fractures of the superior maxillary bones. 

Ordinary fracture symptoms, generally accompanied by great 
swelling. 

Common seat of fracture, alveolar process — at times nasal pro- 
cess, malar process, or body of maxilla. The anterior wall of 
the antrum may be driven in. 

How do you treat fractures of the superior maxilla? 

Reduce, if deformity. If the bone is driven in, raise by pres- 
sure applied from the mouth, or by means of an elevator passed 
through a small skin wound. Retain alveolar process by making 
the lower jaw the splint, applying a Barton's bandage ; treat 
swelling and inflammation by evaporating lotion, applied on lint 
(alcohol and water equal parts). 

Describe fractures of the inferior maxilla. 

Usual seat. Near or through the anterior mental foramen. 

Fractures also occur at the symphysis ; through any part of 
the body ; through the ramus ; through the condyloid process ; 
through the coronoid process. 

These fractures are often compound, from rupture of the mu- 
cous membrane. 

Give the symptoms of fracture of the inferior maxilla. 

Body. The cardinal signs of fracture, together with pain, 
swelling, dribbling of saliva, disability. The central portion of 



114 ESSENTIALS OF SURGERY. 

the bone is pulled downward and backward by the digastric, 
geniohyoid, and geniohyoglossus muscles. 

Fractures of the ramus give little deformity, the bone being held 
in place by the masseter without, the internal pterygoid within. 
Manipulation elicits mobility and crepitus. 

In fractures of the neck, the condyle is pulled forward and in- 
ward by the external pterygoid, causing great pain and crepitus 
on opening or closing the mouth. 

Give the treatment for fracture of the inferior maxilla. 

Careful reduction and the application of a moulded pasteboard 
splint, well padded with cotton, and held in place by a Barton's 
or Gibson's bandage. Frequently wash the mouth with satu- 
rated solution of boracic acid. 

If the dressing fails to keep the fragments in proper position, 
they should be drilled and wired in place. The dressing can be 
removed in five weeks. 

Give the symptoms of fracture of the hyoid bone. 

Seat of injury. Greater horn. Pain on eating or speaking, 
together with the cardinal signs of fracture, elicited by exami- 
ning with the fingers of one hand in the pharynx, while the other 
hand outlines the bone from without. The displacing factor is 
the middle constrictor. 

Give the treatment for fractures of the hyoid bone. 

Reduce by pressure, keep the head between flexion and exten- 
sion, support by a pasteboard collar, give nutrient enemata for 
four days, then, if dysphagia be still great, feed by the oesopha- 
geal tube. 

Give the symptoms of fracture of the laryngeal cartilages. 

Usual seat. Thyroid cartilage. Symptoms — Aphonia, dys- 
pnoea, and bloody expectoration, together with emphysema, deform- 
ity, and possibly moist crepitus. 

Treatment. On the appearance of dyspnoea, intubation, or, 
that failing, tracheotomy. Feed by rectum for some days, and 
secure absolute rest to the parts. 

Describe fractures of the clavicle. 

Cause. Usually indirect violence, as falls on the palm of the 
hand. 



FRACTURES. 115 

Seat. May be any portion of the bone, generally outer portion 
of middle third. 

Direction. Oblique. 

Displacement. Shoulder falls downward, forward, and inward, 
shortening detected by measurement from middle of upper 
border of sternum to coracoid process. 

What causes the displacement in fractured clavicle? 

The outer fragment drops downward, inward, and forward 
from the weight of the shoulder, and the action of the two pecto- 
rals, the latissimus dorsi and the serratus magnus ; the inner 
extremity of the outer fragment is thrown somewhat backward 
by the rhomboidei and levator anguli scapuli, so that it lies 
behind and below the outer extremity of the inner fragment, 
which is slightly tilted up by the sterno-cleido mastoid. 

Give the symptoms of fractured clavicle. 

Crepitus and preternatural mobility readily elicited by pushing 
up and rotating the humerus. 

Deformity detected by passing the finger along the subcutane- 
ous surface of the bone, by inspection, by measurement ; shoulder 
flattened, arm disabled. 

Fractures of acromial and sternal end necessarily allow of but 
little displacement. If external to conoid and trapezoid liga- 
ments, there is marked displacement of the outer fragment. 

Give the treatment for fractured clavicle. 

The object of the treatment is to restore the fragments to their 
proper position by forcing the shoulder upward, outward, and 
backward. This is accomplished by — 

1. Sayre's dressing. Strips of adhesive plaster three and one- 
half inches wide. The first is long enough to surround the body 
including the arm. This strip encircles the arm over the inser- 
tion of the deltoid in the form of a loosely fitting loop, which must 
be made secure by sewing. Draw the arm somewhat down- 
ward and backward, to make tense the clavicular origin of the 
pectoralis major, and fasten it in this position by carrying the 
strip entirely around the body securing it to itself in the back. 

The second strip begins at the sound shoulder, is carried ob- 
liquely over the back to the elbow of the injured side, which is 



116 



ESSENTIALS OF SURGERY. 



received in a slit provided for the purpose, it is then carried 
upward across the front of the chest to its point of origin. This 
forces the shoulder upward, backward, and, by pulling the elbow 



in, also outward. 



Fig. 9. 






2. The recumbent posture, supine, with the arm carried across 
the chest, is the best theoretical treatment for this injury. 

3. VelpeaiCs dressing. A pad fastened in the axilla of the in- 
jured side. The forearm flexed on the arm and carried across the 
chest till the hand rests on or near the sound shoulder. Careful 
manipulation of the fragments into proper position, and the ap- 
plication of Yelpeau's bandage. 

4. DisaulVs dressing. A pad fixed in the axilla by the first 
roller. The arm bound to the side by the second roller. The 
shoulder pressed upward and backward by the third roller. 

Union in about four weeks ; carry the arm in a sling for one 
or two weeks longer. 

Describe fractures of the scapula. 

Cause of fracture. Direct violence. 

Seats of fracture through 1. Body or inferior angle. 2. Surgical 
neck (supra-scapular notch). 3. Glenoid cavity. 4. Acromion 
or coracoid processes. 

What are the symptoms of fractured scapula ? 

In all situations there are found disability, pain, swelling, crepi- 
tus, and preternatural mobility. 



FRACTURES. 



117 



Fig. 12. 



Neck (through suprascapular notch). Disability complete. 
If conoid and trapezoid ligaments are torn there will be a space 
between the acromion and humerus — disappearing on pressing 
the arm upward, but recurring again when the support is 
removed. Coracoid process moves with humerus, the acromion 
remains fixed. 

Acromion process. If behind the acromioclavicular articula- 
tion the shoulder is flattened, and drops downward, forward, 
and inward. Crepitus and undue mobility. 

Coracoid process. Complete disability. Unnatural motion 
may be felt by pressing a finger deeply in the region of this pro- 
cess and pushing up the elbow. 

Give the treatment for fractures of the scapula. 

Body. Compress to both borders of the scapula, adhesive 
plaster extending circularly from the spine to the sternum, 
Velpeau or Desault bandage, with the arm vertically to the side. 

Neck, glenoid cavity, acromion or cora- 
coid process. Towel in axilla, and Vel- 
peau or Desault bandage. 

Describe fractures of the humerus. 

Muscular attachments. 

To greater tuberosity. Supraspina- 
tus, infraspinatus, and teres minor. 

To lesser tuberosity. Subscapularis. 
Anterior bicipital ridge. Pectoralis 
major. Posterior bicipital ridge. La- 
tissimus dorsi, teres major. Shaft. 
Coraco-brachialis, deltoid, triceps. In- 
ternal condyle. Pronator radii teres and 
common flexor tendon. External con- 
dyle and condyloid ridge. The two supi- 
nators, anconeus, extensor carpi radialis longior, and the com- 
mon extensor tendon. 

There may be fractures of the head, anatomical neck, tuber- 
osities, surgical neck, including epiphysis, shaft ; there may be 
supra-condyloid, inter-condyloid, T or comminuted, condyloid, 
epicondyloid (internal only) fractures. 




Comminuted or T fracture. 



118 ESSENTIALS OF SURGERY. 

Give the symptoms of fractured humerus. 

In all, except the impacted fractures of the anatomical neck, 
there are pain, crepitus, preternatural mobility, deformity, dis- 
ability, and swelling. 

Head and anatomical 'neck. Symptoms obscure, slight short- 
ening, crepitus on upward pressure and rotation, broken ex- 
tremity may be felt in axilla. 

Greater tuberosity. Depression under acromion process, widen- 
ing of shoulder, smooth bony prominence (head of bone) under 
coracoid, crepitus on rotation and pressing tubercles together, 
external rotation cannot be performed by the patient. 

Surgical neck. (That portion of the shaft of the humerus lying 
between the tuberosities and the insertion of the latissimus 
dorsi and teres major muscles.) Commonest seat of fracture. 
Direction transverse. Shortening (measured between acromion 
process and external condyle). Lower fragment drawn inward 
and forward by latissimus dorsi, pectoralis major, and teres 
major, pulled upward by deltoid, biceps, triceps, and coraco- 
brachial. Rough end of lower fragment felt near coracoid 
process. Unnatural mobility and crepitus on extension and 
rotation. 

Epiphyseal. As in surgical neck, except that it occurs in 
young people, and that the crepitus is moist and the fragments 
smooth. 

Shaft of humerus. Mostly below middle third. Direction 
oblique. Deformity, overlapping, from biceps and triceps ; if 
above insertion of the deltoid the lower fragment is pulled out- 
ward by that muscle ; if below, the upper fragment is tilted for- 
ward. Cardinal signs of fracture readily detected. 

Supra-condyloid. Projection in front and behind. That in 
front is due to the rough end of the upper fragment ; that 
behind is due to the condyles and olecranon occupying their 
normal relation in regard to each other. Shortening between 
acromion process and external condyle. Reduction easy, but 
deformity promptly recurs. 

Intercondyloid. Increased breadth between the condyles, and 
crepitus elicited by pressing and rubbing them together. 



FRACTURES. 



119 



Condyloid. Crepitus and mobility on manipulating the bony 
prominences, displacement slight. 

All fractures about the elbow-joint are accompanied by great 
and rapid swelling. 



Fig. 13. 



Fig. 14. 





Fracture of the lower extremity 
of the humerus. 



Dressing for fracture of the upper 
third of the humerus. 



Give the treatment for fractures of the humerus. 

TJ'pper extremity. Including intra- and extra-capsular, trochan- 
teric, and fractures of the surgical neck. 

Fasten a folded towel in the axilla by a bandage and adhesive 
strap. 

Flex the arm, and carry the elbow slightly forward, apply a 
spiral reversed from the hand to the seat of fracture. Place a 
moulded pasteboard cap, or three straight, narrow, external 
splints, reaching from the acromion process to the external 
condyle, upon the outer aspect of the arm and shoulder, bind 
in place by a few circular turns of a roller, and complete the 
dressing by fastening the arm to the side, and slinging the fore- 
arm at the wrist. 



120 



ESSENTIALS OF SURGERY. 



Shaft of humerus. Primary roller up to the seat of fracture, 
well padded internal angular splint, avoiding pressure upon 
internal condyle, shoulder cap extending to external condyle 
or below on forearm, arm bound to the side by circular turns 
of the roller, and slung at the wrist. 

If obstinate deformity from outward tilting by the deltoid, 
relax by dressing in the abducted position for a few days. 

Fig. 15. 




Anterior angular splints. 



Supra-condyloid. Internal angular and external moulded 
splint, or anterior angular splint and posterior moulded trough. 
Condyloid. Very obtuse angled, anterior, or internal splint. 

What complications may arise in the treatment of these frac- 
tures ? 

1. Non-union, always in intracapsular fractures, frequently 
in fractures of the shaft. 

2. Paralysis, from injury to the musculo-spiral or ulnar nerves. 

3. Anchylosis, from inflammation within or about the joints, 
particularly the elbow. 



FRACTURES. 121 

How do you avoid anchylosis in fractures about the joints ? 

By practising passive motion. Begin in four weeks for the 
shoulder-joint ; one week for the elbow. Promptly treat inflam- 
mation by cold, local depletion, aspiration at times, and pressure. 

How long do you continue treatment ? 

Five to eight weeks, replacing the splints with a sling in that 
time. 

What fractures occur in the ulna? 

Seats of fractures: shaft, olecranon, styloid or coronoid pro- 
cesses. 

Cause, direct or indirect violence. Usual seat lower third. 

Give the symptoms of fractured ulna. 

Cardinal symptoms as in all fractures. 

Shaft, being subcutaneous, deformity, crepitus and undue 
mobility readily recognized. 

Olecranon. Loss of power to extend, undue mobility ; crepitus 
on extending forearm and pressing olecranon in position. Dis- 
placement often very slight. If aponeurosis is torn through, 
the process is drawn well up the arm from between the condyles, 
leaving a perceptible gap. 

Coronoid process. Very rare. Tendency to backward luxation 
of ulna, movable bony prominence in front. 

Styloid process. Mobility. Crepitus detected by carrying 
hand towards radial border. 

Give the treatment for fractures of the ulna. 

Olecranon. Figure-of-eight about the joint, the upper segment 
looping behind the displaced fragment, pulling it downward. 
Application of a very obtuse anterior or internal angular splint. 

Shaft. Two well padded splints, each wider than the forearm, 
one reaching from the internal condyle to the tips of the fingers, 
the other from the external condyle to the metacarpo-phalangeal 
articulation. Reduce the fracture, apply splints, with the hand 
midway between pronation and supination. Support the fore- 
arm through its whole extent by a handkerchief. 



122 



ESSENTIALS OF SURGERY. 



Coronoid process. Anterior angular splint and compress, 
Passive motion in three weeks. 

Fig. 16. 




Dressing for fractures of one or both bones of the forearm. 

Styloid process. Keduce, apply a compress. Bandage to a 
Bond splint, or apply anterior and posterior straight splints. 

Describe fractures of the radius. 

Seats of fracture. Head, neck, shaft, lower extremity. Ordi- 
nary seat, lower extremity. 

Muscular attachments. Biceps, supinator brevis, pronator 
radii teres, pronator quadratus. supinator longus. 

What fractures occur at the lower extremity of the radius ? 

Barton's (rare). A chipping off of the posterior lip of the 
articular surface. 

Colles's. Common. A transverse break £ inch to 1^ inches 
above the joint. 

Smith's. A transverse fracture 1£ inches to 2| inches above 
the joint. 



FRACTURES. 
Fig. 17. 



123 




Give the symptoms of fractured radius. 

Cause. Fall on the palm of the hand. Direct violence. 

Lower extremity. Silver fork deformity. Lower fragment lies 
posterior to the upper fragment. Hand carried towards radial 
side by supinator longus, extensor carpi radialis, and extensors 
of the thumb. Crepitus and mobility on rotation. All symp- 
toms marked. 

Shaft. Upper fragment slightly tilted forward by biceps, 
and, if above insertion of pronator radii teres (middle third), 
supinated by biceps and supinator brevis. Lower fragment pro- 
nated by two pronator muscles, tilted towards ulna by pronator 
quadratus and supinator longus. If below the insertion of the 
pronator radii teres, deformity as before, except that both frag- 
ments are midway between pronation and supination. Crepitus 
and mobility elicited by rotation. 

Neck of radius. Upper fragment supinated by short supinator, 
lower fragment pulled forward by biceps. Crepitus, mobility, 
and deformity detected by pressing the thumb into the bend of 
the elbow and rotating the forearm. 

Both bones. Usual seat lower third. Shortening and angular- 
ity often marked. Crepitus, unnatural mobility by grasping the 
bones on either side of the fracture and manipulating, or by 
placing the thumb upon the head of the radius, making exten- 
sion, and rotating. 

Upper fragments pulled forward by biceps, brachialis anticus, 
and pronator radii teres. Lower fragments approximated by 
pronator quadratus ; overlapping from the action of the flexors 
and extensors. 



124 



ESSENTIALS OF SURGERY 



How do you treat fractures of the radius? 

Neck. Anterior angular splint, and compress over upper end 
of displaced shaft. Dress in supination. 

Shaft. As for shaft of ulna. Reduce by extension, counter- 
extension, manipulation. 

Loiver extremity. Reduction most important. Fragments 
once placed in proper position usually remain so. 

Fig. 18. 




Bond's splint. 



Reduce thoroughly by extension, pressure, and manipulation. 
Apply a Levis or a Bond splint, a dorsal splint, or simple circu- 
lar strips of adhesive plaster. In all cases leave the fingers free, 
and encouraging their use. The Bond splint requires two 
pyramidal pads, the base of the posterior one to go over the 
upper extremity of the lower fragment, the apex pointing 
toward the fingers. The base of the anterior one to go under 
the lower extremity of the upper fragment, the apex pointing 
toward the elbow. Firm union in four to five weeks. 

Fractures of both bones, or shaft of either, including Colles-S frac- 
ture, complicated by a fracture of the styloid process of the ulna. 

Two straight splints wider than the forearm, as in fractures 
of the shaft of the ulna. 

Sling all fractures of the forearm by means of a handkerchief 
supporting it throughout its entire extent. 

What forearm fractures are dressed in supination ? 

Dress fractures above the insertion of the pronator radii 
teres with the palm up ; in all other fractures, dress with the 
thumb up (midway between pronation and supination). 



FRACTURES. 125 

Describe fractures of the metacarpus. 

Usually second or fifth. Posterior angular projection, from 
distal end of bone being pulled forward by the flexors. Crepitus 
and mobility elicited by seizing and manipulating the two ex- 
tremities of the bone. 

Give the treatment for fractures of the metacarpus. 

Treat by an anterior splint to the hand and forearm, padding 
well to preserve the concavity of the palm. Compress poste- 
riorly if any tendency to deformity. Ketain the dressing for five 
weeks. Passive motion in three days. 

Describe fractures of the phalanges. 

Bare. Due to direct force ; readily diagnosed by manipulating 
the finger bones. Treat by anterior moulded, posterior straight 
splint, extending to the wrist. A long palmar splint may be 
used. 

Describe fractures of the pelvis. 

Cause. Great and direct violence. 

Seats. Crest of ilium, basin of pelvis, acetabulum, sacrum, 
or coccyx. 

Symptoms. In all these fractures there is a sense of falling 
apart. 

Crest. Patient leans toward the affected side ; crepitus and 
mobility on grasping and manipulating the bone. External 
evidence of injury, discoloration, swelling, etc. 

Pelvic basin. Crepitus and mobility may be elicited by grasp- 
ing the iliac spines and attempting to move them in opposite 
directions ; great pain, and inability to sit or stand ; often a 
line of ecchymosis along Poupart's ligament and the crest of 
the ilium. Examination per rectum or vagina may reveal dis- 
placement or crepitus. 

Acetabulum. Either the floor or the rim may be fractured ; 
caused by blows on the trochanter. 

Floor. Great pain on attempting to stand, or in any way 
moving the femur ; crepitus best detected by thrusting the femur 
directly upward ; very slight shortening. 

Rim. Usually the upper and posterior part is broken off. 



126 ESSENTIALS OF SURGERY. 

Subluxation of femur backward. On circumduction, the head 
of the bone can be felt to slip out at a certain point, returning to 
its proper position as the motion is continued ; there is crepitus. 
Sacrum and coccyx. Direction transverse. Cause, direct vio- 
lence. There may be some anterior projection from the action 
of the coccygeus and levator ani muscles. Crepitus and mobility, 
detected by a finger in the rectum. Pain on defecation. 

How are these fractures treated ? 

Place the patient on a fracture bed, i. e., a firm, hard, evenly 
padded bed, with a central perforation through which the con- 
tents of the bowel may be passed without moving the patient. 
Apply a broad bandage or binder tightly about the pelvis ; tie 
the knees together. The most comfortable position is usually 
on the back, with the thighs and knees flexed, and supported by 
pillows ; allow the patient to assume the position of his choice. 
If there is displacement of the coccyx, pack the rectum with 
iodoform gauze or an inflated rubber bag. 

Fractures of the acetabulum are treated by extension, and 
sand bags or splints, as fractures of the femur. 

Describe fractures of the femur. 

Muscular attachment — 

To greater trochanter — Two gluteals (medius and minimus), two 
obturators, two gemelli, pyriformis, quadratus femoris. All ex- 
ternal rotators except the glutei. 

Lesser trochanter — Psoas, iliacus (below), both flexors and ex- 
ternal rotators. 

Condyles — Gastrocnemius, plantaris, and popliteus. 

Seats of fracture. Neck — Intracapsular, extracapsular, mixed. 

Shaft. Lower extremity — Supracondyloid, intercondyloid, T 
or comminuted, and condyloid. 

Give the symptoms of intracapsular fracture of femur. 

Occurs in aged people, frequently females, from slight violence. 
Hip flattened, trochanter less prominent, and lying nearer to 
the anterior superior spinous process of the ilium, with its upper 
border above Nela ton's line (a line from the anterior superior 
iliac spine to the tuberosity of the ischium). 



FRACTURES. 127 

Crepitus elicited by pressure upon the trochanter, and making 
traction and internal rotation. Pain on motion. Preternatural 
mobility, foot can be everted till the heel looks directly upward. 
Swelling not accompanied by marked ecchymosis. Shortening 
from ^ to H inches ; may be slight at first and progressively 
increase. Loss of power. 

Fig. 19. Fig. 2& 




Lines of fracture of the upper extremity Intracapsular fracture of 

of the femur. the neck of the femur. 

Give the symptoms of extracapsular fracture of the femur. 

Cause. Considerable direct violence. It occurs in middle- 
aged males, with well-marked external evidence of injury, i. e. T 
swelling and discoloration. 

Crepitus distinct, harsh, readity elicited. 

Shortening marked, 1 to 2£ inches. 

Give the symptoms of impacted fracture of the hip joint. 

The impacted fracture may be either intra- or extracapsular. 
There will be : 1. No crepitus. 2. Slight shortening, not dis- 
appearing on traction. 3. Loss of function in the iimb, but not 
absolute. 4. Evidence of much injury to the soft parts. 

The foot may be inverted or everted. 



128 ESSENTIALS OF SURGERY. 

Give the symptoms of fracture of the great trochanter. 

This injury often accompanies extracapsular fracture, but may 
exist alone. Cause. Direct violence. It is characterized by 
pain, swelling, discoloration, and crepitus. Unnatural mobility 
elicited by pressing into place the broken fragment, whicn may 
be felt as a hard lump upon the dorsum of the ilium. 

Give the symptoms of fracture of the shaft of the femur. 

Cause. Direct violence. 

Common seat. Middle third. Direction Oblique. 

E version of foot, very marked ; shortening, increased mobility, 
crepitus, loss of power. Upper fragment, especially in the upper 
third, drawn forward and everted by psoas, iliacus, and external 
rotators ; lower fragment pulled up and in by adductors, flexors, 
and extensors. 

Give the symptoms of fracture of the lower extremity of the 
femur. 

Supracondyloid. Lower fragment pulled back by gastrocne- 
mius, shortening, and eversion. 

Intercondyloid, condyloid, or T {transverse and inter condyloid). 
Increased measurement between the condyles, associated with 
great and rapid swelling of the knee. Undue mobility and 

Fig. 21. 




Extension applied for fracture of the femur. 

crepitus, elicited by bending the knee, or by grasping the con- 
dyles and pushing them in opposite directions. Very great 
pain. 



FRACTURES, 



129 



How do you treat fractures of the femur? 

Upper extremity and shaft. Extension by adhesive plaster 2£ 
inches wide and long enough to extend from the upper end of 
the lower fragment, on both sides of the limb, and leave a 4 to 6 
inch loop hanging free below the sole of the foot ; in this loop is 
laid a piece of thin splint board 2| inches wide, and so long, that 
when traction is made, the plaster will stand free from the 
malleoli. This board is fastened in place, and through a hole 
in its centre a cord or bandage is passed. The adhesive plaster 
is placed along the inner and outer aspect of the limb up to the 
seat of fracture, and secured in place by a few strips carried 
around the limb, and a neatly applied spiral reversed bandage 
of the lower extremity. After an hour or two the plaster is 

Fig. 22. 




Dressing for fractured femur. 



tightly adherent, when the extending cord is carried over a 
pulley, a weight is attached, and a pad of oakum is put beneath 
the tendo Achillis. A sand-bag, or a bran-bag and straight 
splint is placed on each side of the leg, the inner extending from 
the sole to the perineum, the outer from the sole to the axilla, 
and the foot of the bed is raised two to four inches to provide for 
counter-extension. The position of the foot is slight eversion, 
and flexion. The inner borders of the inner malleolus, internal 
condyle, and ball of the great toe should lie nearly in the same 
vertical plane, the great toe pointing directly upward. 

Fractures of the upper extremity or shaft of the femur may 
also be treated by well-padded straight internal and external 
9 



130 ESSENTIALS OF SURGERY. 

splints. The shaft may be treated by plaster or other fixed 
bandage, or by straight short splints buckled about the seat of 
fracture. In all cases, except in impacted fracture, extension 
should be used. 

What dressing should be applied when the upper fragment pro- 
jects anteriorly ? 

Kelax the psoas and iliacus by flexing the thigh and support- 
ing it and the leg upon a double inclined plane, raise to such an 
angle that the deformity is corrected. Apply the extension 
plaster from the knee to the upper end of the lower fragment, 
make a stirrup as before, then carry the extending cord over 
a pulley, so elevated that traction is made in the long axis of the 
femur. 

Give the treatment for fractures of the great trochanter. 

A bandage about the hips with a moulded cap to keep the 
trochanter in position, and a long straight external splint ex- 
tending from the axilla to sole. 

How do you treat fracture of the lower extremity of the femur ? 

If there is obstinate angular deformity, section of tendo 
Achillis. If marked shortening, extension as before, carried 
not quite up to the seat of fracture. A splint, or long fracture- 
box, well padded with pillows, should be used. Evaporating 
lotions, or aspiration, for accompanying synovitis. 

How long should treatment be continued in fractures of the 
femur ? 

Treatment, five to eight weeks. Passive motion of the knee 
joint after fourteen days. Massage before allowing the patient 
to put the leg down. Application of plaster, or other fixed 
dressing about the fracture, before walking is allowed. 

How do you treat fracture of the femur in infants ? 

Reduce by extension, counter-extension, manipulation. Place 
in position a carefully padded external splint extending from 
the axilla to the sole of the foot, and fasten it in place by a, 
Silica or planter pressing. Treatment for four weeks,. .... 






FRACTURES. 131 

How do you distinguish between intracapsular and extracap- 
sular fractures of the femur ? 

In extracapsular — 

1. Crepitus is rougher, more readily elicited, and feels as 
though immediately beneath the fingers of the surgeon. 

2. Swelling and discoloration are greater and more immediate. 

3. Deformity or shortening is more marked, but eversion can- 
not be carried so far as in intracapsular fracture. 

4. On rotation the trochanter is found to pass through an arc 
of less radius in extracapsular fractures. 

Describe fractures of the patella. 

Causes. Direct violence, and muscular action. 

Direction. Transverse or longitudinal. Generally, but not 
always, marked separation of fragments. 
Give the symptoms of fractured patella. 

Power of extension lost. Gap between fragments, increased 
on flexion. Great swelling. In longitudinal fractures, crepitus 
and mobility on grasping the two sides of the bone and pressing 
in opposite directions. 

How do you treat fractures of the patella ? 

If there is not much separation, elevate and apply a straight 
posterior splint to the thigh and leg. If great swelling, cold and 
evaporating lotions for one or two days, aspirating the joint if 
necessary. The posterior straight splint is provided with lateral 
pegs and ratchets, to which are attached strips of adhesive 
plaster which are looped over the upper and lower fragments ; 
by turning these pegs, the lower fragment is steadied, and the 
upper fragment is drawn down in position. Fix the lower 
fragment first, then the upper. Imbricate the plaster strips 
from above downward. If the edges of the fragments tilt for- 
ward, carry a piece of strapping transversely around the limb. 
Complete: the. dressing with a figure-of-eight bandage. Begin 
passive motion in two or three weeks. Continue the splint for 
six or eight weeks. Follow with a stiff bandage, plaster or 
glass, and keep the patient on crutches for several months. 

These fractures may also be treated by Malgaigne's hooks, 
by Barker's method of subcutaneous wiring, or by making a 



132 



ESSENTIALS OF SURGERY. 



transverse incision, clearing the breach between the fragments 
and the knee joint of all clots or blood, drilling the fragments 
obliquely (sparing the cartilage), and wiring them in close con- 
tact. 

Fig. 23. Give the symptoms of fracture of the tibia ? 

Usual seat, lower third. Cause, direct or 
indirect violence. Deformity, slight, detected 
by passing the finger along the subcutaneous 
edge of the bone. Mobility and crepitus can 
usually be elicited by extension and counter- 
extension. 

What are the symptoms of fracture of the 
fibula? 

Cause, direct or indirect violence. Seat of 
fracture, lower third. Fracture of lower fifth 
is termed PoWs fracture. Symptoms obscure, 
disability and deformity being slight. Crepi- 
tus and mobility detected by placing the fin- 
gers over the seat of fracture and rotating, 
or by pressure on both sides of the suspected 
Pott's fracture. point. 

What is Pott's fracture? 

A fracture of the fibula, two to four inches above its lower ex- 
tremity ; the foot is displaced outward at the ankle-joint. The 
internal lateral ligament is frequently torn. There may be a 
fracture of the internal malleolus also. 

What are the symptoms of Pott's fracture? 

A well-marked depression at the seat of fracture. Crepitus 
and mobility on local pressure. The foot is twisted outwards and 
the sole everted by the peronei muscles ; the internal malleolus 
projects prominently as if broken, and the fragments can be dis- 
tinctly felt. 

Describe fracture of both tibia and fibula. 

Usual cause, indirect force. Seat of fracture, lower third. 
Direction of fracture, oblique. Deformity, dependent on direc- 
tion of fracture, there is usually overlapping, and anterior pro- 




FRACTURES. 



133 



jection of the upper or lower fragment, 
signs and symptoms. 



Diagnosis, all cardinal 



Fig. 24. 




Fracture-box. 



How do you treat fractures of the leg? 

All these fractures may be treated by the fracture-box, apply- 
ing lateral compresses to correct deformity, and using extension 
if there is marked shortening. The fracture-box should fix 
the knee-joint, should be strong, and 
should hold the leg in such a position 
that the inner borders of the inter- 
nal condyle, the internal malleolus, 
and the ball of the great toe lie 
nearly in the same vertical plane, 
and the foot is kept at right angles 
to the leg, pressure being taken off 
the heel by a pad of oakum beneath 

the tendo Achillis. For very marked displacement, and diffi- 
culty in retention, flex the hip and knee, lay the limb on its 
outer side, and bind it to a double-angled external splint for a 
few days, then place it in the fracture-box. 

The fracture-box consists of a posterior splint, with a foot- 
piece and hinged sides ; a pillow is placed in the box, the leg 
placed on the pillow, and the sides brought up and tied. 

External, posterior, anterior, and straight moulded splints 
may also be used for these fractures. 

PoWs fracture may be treated with Dupuytren's splint. This 
consists of a straight internal splint, notched at the lower end, 
and extending from the head of 
the tibia to a point four inches be- 
low the side of the foot. The up- 
per part of the splint is fastened 
to the leg, a thick pad is applied 
to the lower portion, not extend- 
ing below the internal malleolus, 

the foot is drawn close to the splint, in the space beneath the 
pad, by a figure-of-eight, so applied that there are no turns 
which make pressure above the external malleolus. The knee 
is then bent, and the leg suspended, or laid on its outer side. 



Fig. 25. 



Dupuytren's splint applied. 



134 



ESSENTIALS OF SURGERY. 



Describe fractures of the tarsal bones. 

Cause, great violence. 

Calcaneum or astragalus. Little displacement, unless the 
tuberosity is separated, when it will be drawn up by the gas- 
trocnemius and soleus. Diagnosis depends on crepitus, pain, 
mobility, and great swelling. 

Treatment. Fracture-box, or fixed dressing after subsidence of 
swelling. For separation and displacement of the tuberosity, ex- 
tend the foot on an anterior or lateral splint, and flex the knee. 

Describe fractures of the sternum. 

Seat, about the junction of the manubrium and gladiolus. 

Cause. Direct violence. Indirect violence (over flexion or 
extension of the body). 

Deformity, readily felt. Irregularity and projection. 

Crepitus and, mobility by extending the body, or causing the 
patient to take a deep inspiration. Embarrassment of respira- 
tion, discoloration. 

This injury is usually a diastasis, or separation of the bone at 
its cartilaginous junction. In this case the lower fragment pro- 
jects anteriorly, the crepitus is smooth, and the true nature of 
the injury is suggested by its location. 

Treatment. Eaise the chest by placing a pillow beneath the 
back, force the patient to take a long breath, giving ether if 
necessary, and press the fragments into place. 

Dressing. Broad compress, held in place by adhesive straps or 
bandages. 

Complications. Mediastinal abscess and necrosis. Treat the 
former by opening at the side of the sternum. 

If the ensiform cartilage is drawn in upon the stomach, caus- 
ing distressing symptoms from pressure, it should be hooked up 
or resected. 

Describe fractures of the ribs. 

Cause. Direct or indirect violence, muscular action. Kibs 
commonly broken, fifth to tenth. 

Ordinary seat of fracture, just anterior to the angle. 



FRACTURES. 135 

Give the symptoms of fractures of the ribs. 

Crepitus and mobility, elicited by the pressure of the thumbs, 
passing from the sternum to the spine. ' Restriction of respira- 
tory movements by a sharp pain or stitch. Displacement, if 
present, is internal from direct force, external from indirect. 

Give the treatment for fractures of the ribs. 

Adhesive strips two and one-half inches wide, running par- 
allel to the ribs, from the spine to the sternum, and each tightly 
applied during expiration. The whole side of the chest is in- 
cluded. 

If displacement exists it must be reduced, by pressure, by 
forcing the patient to inspire deeply under ether, or by hooking 
up with a tenaculum. 

What complications accompany fractured ribs ? 

Laceration of the lung, pleura, or an intercostal artery. 

How do you treat the complications ? 

Open and tie, if there are signs and symptoms of internal 
bleeding. Subsequent pleurisy and pneumonia are usually local- 
ized and conservative. Emphysema may require openings in 
the skin (strict asepsis). 

In what fractures is the union ligamentous ? 

Neck of the femur, olecranon, acromion coracoid and coronoid 
processes, patella, tuberosity of the os calcis, spinous processes 
of the vertebrae. This is due, in part, to the difficulty in securing 
or maintaining apposition. 

Describe fractures of the vertebrae. 

Cause. Direct or indirect violence. 

Seats. Spinous processes. Laminae. Body. 

Give the symptoms of fractured vertebrae. 

Crepitus, mobility, and deformity may be detected by grasping 
and manipulating the spinous process, or pressing upon them, or 
by examination through the pharynx, in fractures of the upper 
cervical vertebrae. There is immediate paralysis of the parts 
below the injury, with loss of control over the bladder and 
rectum. Temperature of the paralyzed part is increased. 



136 ESSENTIALS OF SURGERY. 

Dor so-lumbar region. Paraplegia, retention and overflow of 
urine, incontinence of faeces. 

Dorsal region. Second to eleventh dorsal. Paralysis of ab- 
dominal muscles, and muscular coat of intestines. Expiration 
markedly embarrassed from involvement of serratus posticus in- 
ferior, quadratus lumborum, sacro-lumbalis, longissimus dorsi. 

Cervico-dorsal, cervical. If above the fifth and sixth cervical 
vertebra?, paralysis of the arms, and more marked embarrass- 
ment of respiration from involvement of the long thoracic 
nerves (fifth and sixth). If above the third and fourth verte- 
brae, instant death, from involvement of the phrenic. Fractures 
of the atlas and axis need not be immediately fatal, since the 
canal is so roomy that the cord may not be encroached upon. 

Odontoid process will cause a prominence in pharynx from sub- 
luxation of the axis. Rigid maintenance of head in one position. 

How do you treat fractures of the vertebrae ? 

If there is displacement, reduce by extension and manipulation. 
Place the patient on an air or water bed, guarding against bed- 
sores by frequent washings with whiskey and alum, and careful 
padding with soft pillows. Move the bowels by enemata. Draw 
the water regularly with a soft, thoroughly aseptic catheter. In 
fractures about the neck, support by means of short sand-bags. 

How do you treat fractures of the extremities complicated by 
delirium tremens ? 

Carefully pad with raw cotton, and put on a fixed dressing, as 
plaster or silica ; when dry, bind the limb in a soft pillow. 



LUXATIONS. 137 



LUXATIONS OR DISLOCATIONS. 

Define luxation. 

A luxation is the displacement of the articular surfaces of a 
joint from their normal relation to each other. 

Name and define the various kinds of luxation. 
In regard to cause — 

1. Traumatic, due to sudden force. 

2. Pathological or spontaneous, due either to alterations of 
the joint from disease (coxalgia), or to paralysis of the surround- 
ing muscles. 

3. Congenital, due to congenital malformation of the joint 
(luxation produced by Violence in delivery is not congenital). 

Further, we have luxation classed as — 

Complete. An entire separation of the articular surfaces from 
each other. 

Partial (subluxation). The articular surfaces remain in con- 
tact through a portion of their surface. 

Recent. When sufficient time has not elapsed for inflam- 
matory changes seriously to impede reduction. 

Old. When such changes have taken place. 

Simple, compound, and complicated are applied to luxations 
precisely as in case of fracture. 

What are the causes of luxation ? 

(1.) Predisposing.— 1. The nature of the joint (ball-and- 
socket joint). 2. The position of the joint. 3. The condition of 
the surrounding soft parts. (Paralysis, relaxation, and previous 
inflammation.) 4. Age and sex of the patient. (Adult male.) 

(2.) Exciting. — Direct or indirect violence. Muscular force. 

What are the cardinal symptoms of luxation ? 

1. Change in the shape of the joint. 

2. Alteration of the normal anatomical relations of the bony 
prominences about the joint, the displaced bone being often felt 
in its abnormal position. 

3. Alteration in the length of the limb. 



138 



ESSENTIALS OF SURGERY. 



4. Eigidity, or restricted motion of the affected joint. 

5. Alteration in the direction of the axis of the bone. 

In addition we have the symptoms attendant on all trauma- 
tisms. 

Pain of a dull sickening character. Swelling often very great. 
Discoloration diffused about the joint. 

How do you distinguish luxations from fractures ? 

1. In luxation there is no harsh crepitus. 

2. There is rigidity in place of undue mobility. 

3. The deformity, when reduced, has not the same tendency 
immediately to recur. 

The pain is not so intense, the swelling and discoloration not 
so rapid, and at times the smooth displaced articular surface 
may be felt, while in fracture, except epiphyseal, the surfaces 
would necessarily be rough. The Rontgen rays may clear up 
doubt. 

What articular changes take place in luxation ? 

Rupture of capsular ligament, with stretching or tearing of 
surrounding vessels, tendons, muscles, and nerves. 

Prompt reduction of the bone favors the repair of the injury. 
If the bone is not reduced the articular cavity becomes filled 
up, the prominences rounded off ; a new socket is formed about 
the displaced head of the bone. The surrounding soft parts 
become shortened and atrophied, and adhesions between the 
bone and the vessels or nerves often take place. 

What is the prognosis in luxation ? 

Usually a weakened joint. If the dislocation is not reduced, 
permanent disability, which, however, is rarely absolute. 

How do you treat luxation ? 

Reduce by either manipulation or extension. 

Describe the methods of reduction. 

1. Manipulation consists in so placing and moving the parts 
that muscles and ligaments are relaxed, articular prominences are 
disentangled from each other, and the head of the bone is either 



LUXATIONS. 139 

drawn by the muscles, or pushed by moderate force into its proper 
position. 

2. Extension consists in overcoming resistance by force — this 
force may be applied by the hands, by wet sheets or bandages 
fastened about the parts, or by multiplying pulleys. When the 
tension is sufficient to overcome all resistance the bone is pushed 
into its proper position. Retain in position by splints and ban- 
dages. 

How do you treat the inflammatory symptoms ? 

Treat by evaporating lotions or counter-irritants. The diet 
should be restricted and the bowels kept opened. 

How do you prevent anchylosis ? 

By passive motion, beginning in seven to ten days, or as soon 
as inflammatory symptoms subside. 

What complications attend luxations ? 

1. Fracture. Treat by setting and splinting the fracture, then 
reducing the luxation. 

2. Rupture of a large artery, indicated by a rapidly increasing, 
fluctuating, pulsating swelling. Treat by rest and pressure, or 
ligate both ends at the point of injury, if it can be found. If 
this is impossible, make a formal ligation of the artery above. 

3. Injury to nerve-trunks. Treat by friction, electricity, mas- 
sage, incision and suture. 

4. External wound, or compound luxation. If no extensive 
injury to the joint, thoroughly disinfect, replace, close the 
wound, and fix. If the bone is comminuted, resect. 

How do you treat an old luxation ? 

Loosen adhesions and relax contracted muscles and ligaments 
by passive motion. Endeavor to replace the bone by manipula- 
tion ; that failing, use force. 

What accidents may occur in the reduction of old luxations ? 

Fractures. Set at once, and give up further attempt. 
Rupture of important muscles. Put at rest. 
Rupture of principal artery. Ligation of artery above, or liga- 
tion of both ends at point of rupture, or amputation. 



140 



ESSENTIALS OF SURGERY. 



Buptured vein. Pressure. 

If an old luxation gives little pain on movement let it alone, 
as the prognosis is good. If great pain, try to reduce, since 
the pain will prevent the patient from endeavoring to restore 
fuuction. 



Special Luxations. 

Describe luxations of the lower jaw. 

Direction is forward. May be unilateral ; more commonly bi- 
lateral. May be partial, the condyles resting on the articular emi- 
nence, or complete the 



Fig. 26. 




Complete luxation of the lower jaw. 



condyles slipping into 
the zygomatic fossa. 

Cause. Violence or 
muscular force, applied 
when the mouth is 
widely opened. In this 
position the condyles 
ride well up on the ar- 
ticular eminence, and 
may be easily pulled 
forward by the action 
of the external ptery- 
goid, and masseter, or 
by direct force. This 
displacement may occur 
in yawning, laughing, 
etc. 



Give the symptoms of dislocation of the jaw. 

Bilateral. Mouth widely opened and rigid, lower jaw thrust 
forwards, lips cannot be approximated, hence dribbling of saliva. 
A depression is felt in the normal position of the condyle, the 
latter forming a prominence in front. Difficult deglutition, pain, 
and swelling. 

Sub-luxation. Condyles and lower jaw slightly anterior to 
normal position, jaw rigidly closed, and great pain. 



LUXATIONS. 141 

Unilateral luxation. Mouth less widely opened, lower jaw 
projected anteriorly, and thrust towards sound side ; displaced 
condyle detected on the affected side ; other symptoms as in 
bilateral luxation. 

Give the treatment for dislocations of the inferior maxilla. 

Disengage the head of the bone from the zygomatic fossa, 
when the internal pterygoids and the masseter and temporal 
muscles will pull it in place. This can be effected by pressing 
downward upon the molar teeth of the lower jaw, at the 
same time pulling up the chin. The protected thumbs of the 
surgeon's hand are placed upon the molar teeth, exerting force 
downward and backward, while, with the fingers, the chin is 
pressed up ; or wedges may be inserted between the molar 
teeth of the lower and upper jaws on each side, and the chin 
forced directly upwards. 

Unilateral luxation. Force exerted as before, on the affected 
side of the jaw. 

Sub-luxation. Slip a case-knife between the teeth of the upper 
and lower jaws, and pry them open, when the muscles promptly 
reduce the displacement. 

Describe luxation of the ribs. 

Occurs at costo-chondral or vertebral articulations. If at verte- 
bral extremity, usually associated with fracture. 
Symptoms as in fracture, except no crepitus. 
Treatment as for fracture. 

Describe luxation of the vertebrae. 

Nearly always complicated by fracture. 

Usual seat. Cervical region. 

Symptoms. Sudden paralysis, rotary or angular deformity, and 
rigidity. 

Treatment. Eeduce by extension and counter-extension in 
the line of the body. Treat subsequently on a water-bed as for 
fracture. 

Describe luxations of the clavicle. 

More frequent at acromial than at sternal extremity. 
Sternal extremity. Forward, by force applied to front of 



142 ESSENTIALS OF SURGERY. 

shoulder. Most common. Backward, by force applied to back 
of shoulder or applied directly on sternal extremity of bone. 
Upward, very rare, by force applied to shoulder from above. 

Give the symptoms of luxations of the sternal end of the 
clavicle. 

Shoulder falls towards median line, pain on motion. Smooth 
articulating surface of bone felt in its abnormal position leaving 
a depression in the seat of its articulation. If luxation back- 
wards or upwards there may be dyspnoea, dysphagia, or venous 
congestion of head, from pressure. 

Give the treatment for luxation of the sternal end of the 
clavicle. 

Forward and backward luxations. Reduce by knee between 
scapulae, pulling shoulders back, and pressing the bone in place. 

Upward luxation. Reduce as above, or by placing a large pad 
in the axilla, pressing the humerus to the side, and pushing the 
bone in place. 

Dressing. Forward luxation. ;Flex arm and apply a Velpeau 
or Desault, keeping the displaced bone in place by compress 
and adhesive strips. 

Backward. Posterior figure-of-eight and Velpeau or Desault. 

Upward. Velpeau bandage, with compress and adhesive 
strips if persistent deformity. 

Describe luxations of the acromial extremity of the clavicle. 

Really luxations of the scapula. 

Direction upward, rarely downward below acromion, or still 
more rarely, below coracoid process. 
Cause. Direct blow on scapula. 

Give the symptoms of luxation of the acromial end of the 
clavicle. 

Upward luxation. Shoulder falls down and in. Arm cannot 
be raised over head. Outer extremity of clavicle very prominent, 
overriding acromion process. ' J 

Downward luxation. Same _symptoms, except the; acromion 
is prominent ; the clavicle leads down to the axilla and can be 



LUXATIONS. 143 

felt in its abnormal position beneath the acromion or coracoid 
process. 

Give the treatment for luxations of the acromial end of the 
clavicle. 

Beduce, by pulling the shoulder backwards and pressing the 
bone in place. Place a compress over the acromial extremity 
of the clavicle and fasten it in place by broad straps passing 
over it and around the point of the elbow. Apply a Velpeau 
bandage. In all luxations of the clavicle reduction easy, reten- 
tion difficult. 

Keep up the dressing for five to six weeks, then carry the arm 
in a sling for some time. 

Describe dislocation of the scapula. 

By this is meant the slipping out of the inferior angle, of the 
bone from beneath the latissimus dorsi. 

Cause. Paralysis of the serratus magnus, or violence. 

Symptoms. Wing-like projection, pain, and weakness of 
shoulder. 

Treatment. Broad belt which will keep the inferior angle of 
the scapula close to the chest. 

Describe the shoulder-joint. 

Characterized by a large ball and small socket, allowing great 
freedom of motion. 

Ligaments. 1. Capsular. Very lax, weakest at lower part, 
attached to margins of glenoid cavity and to anatomical neck 
of humerus. 

2. Coraco-humeral. Passing from root of coracoid process 
downward and outward to the front of the great tuberosity. 

3. Glenoid. A triangular ring of fibro-cartilage, deepening the 
glenoid cavity. The joint is further strengthened by the tendon 
of the biceps passing directly over it, and invested in a prolonga- 
tion of its synovial membrane. 

Name the luxations of the shoulder-joint. 

Four in number, Subglenoid, subcoraQOid, subclavicular* and 
$ubspinou&, 



144 ESSENTIALS OF SURGERY. 

Fig. 27. Fig. 28. 




Subclavicular. 



Subspinous. 



What symptoms are common to all shoulder luxations ? 

1. Flattening and squareness of the shoulder, with apparent 
projection of acromion process. 



LUXATIONS. 145 

2. A depression beneath the acromion process, where the head 
should lie. 

3. The head of the bone can be felt in its abnormal position. 

4. The vertical measurement 'of the shoulders, from the axilla 
around the acromion process, is 'one or two inches greater on the 
affected side than on the sound |ide. 

5. With the elbow brought clJse to the body, the patient can- 
not place the hand of the injured side upon the opposite shoulder 
(except in subspinous). 

6. Alteration in the axis of the humerus. 

7. Bigidity, pain, swelling, discoloration, etc. 

What symptoms characterize subcoracoid luxation ? 

This is the most common luxation. 1. Head of bone can be 
felt in the upper and anterior part of the axilla, beneath the 
coracoid process. 

2. The humerus stands from the side (deltoid), and is some- 
what oblique in direction, the elbow being carried back (latissi- 
mus dorsi and teres major). 

3. Pressure on axillary plexus especially marked, and conse- 
quent numbness and tingling in the arm and forearm. 

What symptoms characterize subglenoid luxation ? 

Next in frequency. Head of bone rests on axillary border of 
scapula, and can be felt in the axilla. Elbow carried far from 
the side (deltoid). Lengthening of the arm, measured from the 
acromion process to the external condyle of humerus. 

What symptoms characterize subspinous luxation? 

Elbow carried somewhat forward (pect. major), and bone 
rotated inward (subscapularis), the forearm being thrown across 
the chest. Head of bone felt on dorsum of the scapula. Cora- 
coid process prominent. 

What symptoms characterize sub-clavicular luxations ? 

Head of bone seen or felt internal to coracoid process, and be- 
low clavicle, much laceration of muscles attached to tuberosities. 
Elbow out and back. All the characteristic symptoms. 
10 



146 



ESSENTIALS OF SURGERY. 



How do you treat luxations of the humerus? 

1. Beduce by manipulation. 

Subglenoid, subcoracoid, and subclavicular. Flex forearm on 
arm (relax long head of biceps) ; raise the arm from the body 
(relax deltoid and supra-spinatus) ; rotate the humerus outward 
(relax infra-spinatus and teres minor); make forcible traction 
upon the humerus with one hand, sweeping it to the side of the 
body and rotating it inward, carrying the forearm across the 
chest, while with the other hand in the axilla the head of the 
bone is pressed into place. 

Subspinous. Flex the forearm, grasping the elbow, carry the 
humerus from the side, rotate inward (subspinous), and with the 
thumb press the head of the bone in place. 

2. Beduce by extension. 

Heel in the axilla. Patient supine, surgeon sits down beside 
him, places his heel (unbooted) in the axilla, and makes traction 

Fig. 31. 




Reduction by extension. 

on the wrist, at first directly downwards. If the luxation is not 
reduced, the humerus is carried across the chest by pulleys. 
Earely employed except in old dislocations. 

After treatment, arm to side and axillary pad for a week, 
passive motion for two weeks, then allow patient to use arm. 
Old luxations. If more than three months have elapsed and 
there is a fair amount of motion, do not attempt to reduce. 



LUXATIONS. 147 



Luxations of Elbow. 

What dislocations may occur at the elbow-joint? 

Eadius. Forwards, backwards, outwards. 

Ulna. Backwards. 

Both bones. Forwards, backwards, inwards, outwards. 

Ordinary luxation. Both bones backwards. 

Describe backward luxation of both bones. 

Cause. Fall on palm of hand. 

May be complete, when coronoid process of ulna is lodged in 
olecranon fossa of humerus, or incomplete, when coronoid process 
rests upon the articulating surface of the humerus (trochlear). 

Give the symptoms of backward luxations of the radius and 
ulna. 

1. Olecranon projects posteriorly, is out of line with condyles, 
and the distance between it and the condyles is greatly in- 
creased. Head of radius felt behind external condyle. 

2. A smooth, broad, rounded projection, the articular ex- 
tremity of the humerus, can be felt in front of the elbow, below 
the joint crease. 

3. The forearm is flexed, supinated, and rigid. 

4. Shortening, from external condyle to styloid process of 
radius. 

Give the symptoms of forward and lateral luxations of radius 
and ulna at the elbow. 

Both bones forward, very rare, forearm lengthened, condyles 
of humerus prominent, sigmoid notch can be felt in front of arm. 

Lateral luxation of both bones. Great deformity. The articu- 
lating extremity of the radius or ulna can be felt in their 
abnormal positions, with marked projection of the condyle from 
which the bones are displaced ; joint widened, forearm flexed 
and pronated. 

Give the symptoms of luxation of the ulna at the elbow. 

Direction, always backward. The symptoms are the same as 
for both bones backward, except that the head of the radius 



148 ESSENTIALS OF SURGERY. 

can be felt in its normal position, and the forearm is shortened 
only on its ulnar aspect. 

Give the symptoms of luxations of the radius at the elbow. 

Directions, forward, backward, outward. 

Forward, due to force applied in supination. 

Backward, due to forcible pronation. In both, the head of 
the bone can be felt in its abnormal position, leaving a hollow 
below the capitellum of the humerus. Motion restricted. 

Give the treatment for luxations at the elbow. 

Dislocation of idna or of both bones. 

Forcible flexion of forearm over the knee placed in the bend 
of the elbow ; or forcible extension of the forearm, followed by 
flexion. 

Badius. Anterior luxation. Flexion of forearm, direct pres- 
sure upon head of radius, and forced pronations. 

Posterior luxation. Flexion of forearm, forced supination, 
direct pressure. 

Dressing. Anterior angular splint one week, with compress, in 
case of radius ; passive motion daily. These luxations become 
old in one or two weeks. If attempt to reduce an old luxation 
is made, first break up adhesions. 

Describe luxations of the carpal extremity of the ulna. 

Cause. Forward, violent supinations. Backward, violent 
pronations. 

Symptoms. Projection, with ordinary symptoms. Triangular 
cartilage always broken. 

Treatment. Press bone in place, apply compress and bandage, 
or adhesive plaster, keep up support for several months. 

Describe luxations of the carpus. 

The wrist-joint is formed by the radius and triangular carti- 
lage articulating with scaphoid, semilunar, and cuneiform bones. 

Cause of luxation. Force applied to hand in front or behind. 

Direction. Backward or forward. 

Symptoms. Thickness of wrist greatly increased. Distance 
between styloid process of radius and base of metacarpal bone 



LUXATIONS. 149 

of thumb lessened. The smooth round projection of the carpal 
bones felt on one surface of the wrist, the more irregular projec- 
tion of the lower extremity of the radius felt on the opposite 
surface. Kigidity, pain, etc. Hand somewhat flexed in poste- 
rior luxation, somewhat extended in anterior luxation. 

Treatment. Posterior displacement. Flex, press carpus for- 
ward, on first sign of slipping into place suddenly extend. 

Anterior displacement. Extend, press carpus backward, and 
on first sign of slipping into place suddenly flex. Keduction 
may be effected by extension and counter-extension. 

Splint and begin passive motion as soon as inflammation sub- 
sides. 

Describe luxation of the individual carpal bones. 

Direction. Backwards. 

Cause. Direct force. 

Common seat. Os magnum. 

Symptoms. Projection at base of third metacarpal bone, 
with ordinary symptoms of luxation. 

Treatment. Extend, press into place, and apply palmar splint 
with compress. 

What luxations may occur in the hand? 

Metacarpus. Rare. 

Direction. Backwards. 

Symptoms. Prominence and shortening. 

Treatment. Extension, pressure, and palmar splint. 

Phalanges. Seat. Usually first phalanx of index or little 
finger. Direction. Anterior or posterior. 

Symptoms. Shortening and undue prominence. 

Treatment. Traction, or extreme extension and forcing bone 
into place by direct pressure. 

What is the most difficult luxation to reduce? 

Backward displacement of first phalanx from the metacarpal 
bone of the thumb. 

What is the cause of difficulty? 

The head of the metacarpal bone slips in between the two 
heads of the short flexor of the thumb, and is embraced the more 



150 



ESSENTIALS OF SURGERY. 



tightly, in proportion to the amount of traction exerted on the 
displaced phalanx. 

What are the symptoms of backward luxation of the first 
phalanx of the thumb ? 

Head of metacarpal bone felt in palmar aspect of hand. 
Proximal phalanx extended, terminal flexed. Immobility, etc. 

Give the treatment. 

Forcibly adduct the metacarpal bone into the palm, extend 
the phalanx far backward till the thumb-nail nearly touches the 
wrist, then suddenly flex on the metacarpal bone, at the same 
time pressing the displaced phalanx into position. If this 
method fails, tenotomy of the flexor brevis pollicis. 

Name the ligaments of the hip-joint. 

1. Cotyloid, a rim of fibro-cartilage deepening the acetabulum. 

2. Transverse, bridges over the notch, and is continuous at 
each end with 



Fig. 32. 



Fig. 33. 





Y-ligament. 



Obturator luxation. 



LUXATIONS. 151 

3. Ligamentum teres, which passes to a depression in the head 
of the femur. 

4. Capsular, encircling the acetabulum above and attached to 
anterior intertrochanteric line, to inner and upper border of the 
great trochanter, and posteriorly and below to the junctions of 
the middle and outer thirds of the neck of the femur. 

5. Y -ligament, a thickened part of the capsular ligament 
rising from the anterior inferior iliac spine and splitting as it 
passes down to be inserted into the intertrochanteric line. 
Lower and inner part of joint is weakest. 

Name the dislocations of the hip-joint. 

1. Up and back on dorsum ilii. Iliac. 

2. Back in sciatic notch. Ischiatic. 

3. Forward and down in obturator foramen. Obturator. 

4. Forward and up on pubis. Suprapubic. 
Causes. Force applied when the limb is abducted. 

What symptoms characterize the backward luxations ? 

1. Dorsum ilii. Upwards and backwards. Bulging of hip from 
displaced trochanter major, which lies above Nelaton^s line and 
nearer the anterior superior spinous process of the ilium than 
on the sound side. 

Shortening, one and one-half inches. Pressing the fingers into 
the groin over the femoral vessels, their firm base or support is 
gone, a hollow is felt instead. Head of the bone may be felt 
beneath glutei muscles. 

Position of leg. Adduction and inversion due to Y -ligament. 
Knee rests against lower third of opposite thigh. Great toe rests 
on instep of opposite foot. 

Higidity, pain, swelling, etc. 

2. Ischiatic or sciatic luxation (below the tendon of the obtu- 
rator). 

Symptoms the same, but less marked. Less shortening, adduc- 
tion, and inversion. 

Knee touches, but does not cross opposite knee. Ball of great 
toe rests on metatarsal bone of opposite side. 



152 ESSENTIALS OF SURGERY. 

Fig. 34. Fig. 35. 





Dorsum ilii. 



Ischiatic. 



Fig. 36. 



Give the treatment of backward luxations, 

Manipulation. Flex leg on thigh (relax hamstring mus- 
cles), thigh on abdomen, and still 
further adduct to relax anterior 
part of capsule ; then maintain- 
ing flexion, circumduct (abduct 
and rotate) outward as far as pos- 
ble, bringing the leg suddenly 
down to an extended position by 
the side of its fellow. By this 
means the head of the bone is 
made to retrace the steps by which 
it escaped, and is wound in place 
by the Y -ligament. 

Manipulation failing, try 
Extension. Secure counter-exten- 
sion by strapping the pelvis to the 
floor or bed. Make extension by 
flexing the thigh on the pelvis and 
pulling directly upward. 




Manipulation for reduction of 
backward luxation. 



LUXATIONS. 



153 



Give the symptoms characterizing forward luxations. 

Obturator luxation forward and downward. 

1. Psoas, iliacus, external rotators, and Y -ligament put upoi* 
the stretch, hence 

Eversion and abduction with slight flexion, thigh being carried 
somewhat forward. 

2. Flattening of hip and, possibly, detection of bone in abnor- 
mal position. 

3. Slight lengthening (one-half inch). 

4. Fixation, swelling, and other signs. 



Fig. 37. 



Fig. 38. 




-^^0*^ 




Suprapubic. 



Suprapubic luxation. 1. Head of bone readily felt on pubis, to 
outer side of femoral artery. 

2. Shortening (1£ inch), with very marked eversion of foot and 
knee, heel inclining towards opposite one. 

3. Trochanter may be internal to anterior superior spinous pro- 



4. Depression over acetabulum. 



154 



ESSENTIALS OF SURGERY 




Give the treatment of forward luxations. 

Reduction. Obturator — Flex leg on thigh, thigh on abdomen, 
abduct somewhat, then circumduct 
inward, carrying thigh over body and 
making internal rotation, and bring 
the leg down to the side of its fellow. 
Suprapubic as for obturator, but 
do not carry the thigh so far across 
the body. 

Give the after-treatment of all luxa« 
tions at the hip-joint. 

The knees bandaged together (a 
towel between them) for ten days, 
passive motion in bed for two weeks, 

Manipulation for reduction of Wearin § moulded su PP ort for three 
forward luxations. months. 

Name the internal ligaments of the knee-joint. 

1. Anterior and posterior crucial. 

2. The transverse ligament, binding together the two semilunar 
cartilages. 

3. The coronary ligament, connecting the outer borders of the 
semilunar cartilages to the head of the tibia. 

4. Ligamentum mucosum, a process of synovial membrane, and 
ligamenta alaria, its fringed borders. 

Describe luxations of the knee-joint. 

Cause — great violence. Directions — Forward, backward, in- 
ward, and outward. 

Lateral dislocations mostly incomplete ; more common than an- 
teroposterior. 

Give the symptoms of backward and forward luxations of the 
knee-joint. 

1. Shortening. 2. Great deformity. The articulating extremi* 
ties of the femur and tibia being readily felt in their abnormal 
positions. 

Give the symptoms of lateral luxations of the knee-joint. 

No shortening, but marked lateral projection of the tibia, with 



LUXATIONS. 155 

a depression above ; condyle of femur prominent on opposite side, 
with a corresponding depression below. 

Give the treatment of luxations of the knee-joint. 

Treatment. Flex the thigh, make extension, and push bone 
in place. Reduction easy. 

Apply a posterior straight splint. Treat the synovitis (cold, 
counter-irritation, etc.), and begin passive motion as soon as 
acute inflammatory symptoms subside. A knee-cap must be 
worn when the patient is allowed to walk. 

In what directions may the patella be dislocated ? 

1. Outwards. (Most common, from oblique attachment of 
quadriceps tendon.) 

2. Inicards. 

3. Quarter rotation. 

4. Half rotation. 

Give the symptoms of luxation of the patella. 

Outward and inward luxations. 

1. Knee flattened and broadened. 

2. Sulcus in normal position of patella. 

3. Patella readily found in abnormal position. 

Give the treatment for lateral luxations of the patella. 

Anaesthetize, flex thigh or abdomen, extend leg on thigh, 
forcibly depress the margin of the patella furthest from the 
centre of the joint, when its inner edge being raised and freed, 
will be snapped into place by the quadriceps. 

Give the symptoms of rotatory luxation of the patella. 

Quarter rotation. 1. Sharp edge of patella felt prominently 
under skin. 2. Leg fixed in extension. 

Half rotation. 1. Tendo patella stands rigidly out and is 
twisted. 2. Smooth articular facets of under portion of patella 
felt. 2. Limb rigidly extended. 

Treatment. Anaesthetize. Rapid flexion and extension of 
leg on thigh. If this fails, employ direct pressure. 

Describe luxation of the semilunar fibro-cartilage. 

Causes. Twists of foot or leg while the knee is flexed. 
Directions. Inward towards spine of tibia, outward. 



156 ESSENTIALS OF SURGERY. 

Give the symptoms of luxation of the semilunar cartilage. 

1. If outward, a projection may be felt between tibia and con« 
dyle of femur. If inward, a depression may be noted in the same 
position. 

2. Sudden, violent, sickening pain. 

3. Leg fixed in senii-flexiom 

4. Rapid effusion into joint. 

Give the treatment for luxations of the semilunar cartilage. 

Forcible flexion, straight posterior splint. Treat accompanying 
synovitis. A knee cap must subsequently be worn. 

Describe luxations at the ankle-joint. 

Directions. Outwards, inwards, forwards, backwards, up- 
wards (between tibia and fibula). 

May be complete or incomplete. Complications. Frequently 
fractures. 

Outward. Always accompanied by fracture of fibula, fre- 
quently of internal malleolus also, or rupture of internal lateral 
ligament. 

Symptoms. As in Pott's fracture (p. 32). Foot everted. In- 
ternal malleolus prominent. 

Inward. Rare. Accompanied by fracture of tibia. 

Symptoms. 1. Foot inverted. 2. External malleolus promi- 
nent and nearly touching ground. 3. Depression over seat of 
fracture. 

Backward. 1. Marked shortening of foot with toes pointed 
downward. 2. Lengthening of heel. 

Forward. 1. Lengthening of foot. 2. Heel less prominent. 
3. Tibia lies close to tendo Achillis, which is relaxed. 

Upward. Caused by heavy fall on feet. 

Symptoms. Joint very wide, malleoli may be prominent and 
nearly on a level with the sole. 

Give the treatment for luxations of the ankle-joint. 

Beduce. Flex leg on thigh, extend ankle-joint to relax muscles 
of calf. Extension must be made at the foot. Counter-extension 
at the thigh, while by manipulation and pressure the bones are 
replaced in their proper position. 



LUXATIONS. 157 

After treatment. Control inflammatory symptoms by evapo- 
rating lotions. Fracture-box, or moulded splints for two weeks, 
then passive motion. 

Describe luxations of the astragalus. 

Directions. Forward, backward, outward, inward. 

Forward, most common. 

Cause. Violent twists. 

Symptoms. In all these luxations the malleoli are nearer the 
sole than they should be. 

Forward. A round smooth swelling upon the instep, with 
ordinary signs of luxation. 

Backward. 1. Hard prominence between tendo Achillis and 
malleoli. 2. End of tibia and fibula prominent anteriorly. 3. 
Foot apparently shortened. 

Lateral luxations. If astragalus is thrust outward the foot is 
displaced inward. Internal malleolus very prominent. 

Inward luxation. Foot displaced outward. External malleo- 
lus prominent. 

Reduce. By traction and direct pressure, under ether. Failing, 
perform tenotomy, dividing all resisting structures. If skin 
sloughs over projecting astragalus, remove the bone. 

Failing to reduce, put in fracture-box and treat as ankle luxa- 
tion. 

Give the differential diagnosis between fracture of the surgical 
neck of the humerus, and luxation about the shoulder- 
joint. 

In fracture, crepitus, unnatural mobility. Head of the tone in 
its normal position, but not moving with shaft. Deformity readily 
overcome, but at once recurring on removal of reducing force ; 
acromion not especially prominent, and no undue space beneath 
it ; jagged bone ends may be felt ; very acute pain. Arm hangs 
to the side. 

Luxation. No crepitus. Rigidity. A hollow in the normal 
position of the head of the bone. Detection of head of bone in 
abnormal position, moving with the shaft. Deformity reduced 
with difficulty, after reduction the bone remains in its normal 
position ; acromion prominent, with a space beneath. Shoulder 
flattened and squared. Arm stands from the side. 



158 ESSENTIALS OF SURGERY. 

Give the differential diagnosis between supracondyloid fracture 
of the humerus, and backward luxation of the radius and 
ulna. 

Fracture. Crepitus, mobility, and all cardinal signs ; olecra- 
non and internal and external condyle in their normal relation to 
each other ; no shortening from external condyle to styloid pro- 
cess of radius, shortening from acromion to external condyle. 

Luxation. Immobility, and all the signs of luxation; olecranon 
displaced backward from its normal position in relation to internal 
and external condyles; shortening from external condyle to 
styloid process of radius, no shortening from acromion to ex- 
ternal condyle. 

The differential diagnosis between any fracture, and a luxation 
in the same region, may readily be given by bearing in mind the 
cardinal symptoms of each affection. 

Sprains. 

What is a sprain ? 

The twisting of a joint, by which the soft parts about it are 
stretched or torn. Muscles, tendons, ligaments, nerves, and 
bloodvessels may be involved. 

What is a sprain fracture ? 

The tearing away of scales of bone to which ligaments are at- 
tached. 

What are the symptoms of sprain ? 

Pain and swelling due to both extravasation of blood, and in- 
flammatory effusion within and without the joint. Discoloration 
and loss of function. 

Give the treatment of sprain. 

Hot fomentations, or hot bath, lasting for several hours, fol- 
lowed by pressure bandage for two to four days. Passive motion 
and massage as soon as the inflammatory symptoms begin to sub- 
side. Or, cold applications and evaporating lotions, followed by 
pressure and massage. 



DISEASES OF JOINTS. 159 

Describe sprains of the back. 

Symptoms. Pain, stiffness, and disability, appearing some time 
after the injury. There may be apparent paresis, together with 
retention of urine and faeces, due to the pain caused by motion. 
There is sometimes hematuria. 

Treatment. Best in the most comfortable position for a few 
days, with local depletion (leeches), hot moist applications 
(antiseptic poultices), and counter-irritants. Then massage and 
use. If there is great pain on motion, a plaster bandage may be 
applied, to be removed as soon as possible. 

Wounds of Joints. 

What symptoms characterize joint wounds ? 

Symptoms of acute inflammation, with distension, due to ef- 
fused blood and synovial fluid, and escape of the latter through 
the external wound. 

If the contents of the joint cavity become infected, the char- 
acteristic symptoms of an acute suppurative synovitis and ar- 
thritis will appear, together with the high fever (103°-105°), and 
marked constitutional symptoms of the affection. 

How do you treat a wounded joint? 

If uncertain as to whether the joint is wounded, do not probe, 
but treat as a wounded joint. 

1. Small incised wounds. Thoroughly disinfect the wound area, 
close promptly, using sutures if necessary. Cover with a scale 
of iodoform and collodion. Carefully splint in the easiest posi- 
tion, and apply cold by means of ice-bags. If marked local and 
general inflammatory symptoms appear, open the joint, and 
treat as— 

2. Large or lacerated wounds. Thoroughly disinfect the entire 
wound area. Wash out the synovial cavity with 1 : 1000 bichlo- 
ride solution, finishing with 1 : 5000. Make a counter opening, 
and insert drainage-tubes. Suture the external wound, apply 
an antiseptic dressing, splint most carefully, and elevate the 
limb. 



160 ESSENTIALS OF SURGERY. 

Synovitis. 

What is synovitis ? 

An inflammation of the synovial membrane of a joint. It may 
be acute or chronic. There may be an effusion consisting of 
synovia and serum, constituting serous synovitis. This effusion 
may become infected, causing purulent synovitis. 

What are the causes of synovitis ? 

Exposure to heat or cold, traumatism, rheumatism, gout, 
syphilis, tuberculosis, gonorrhoea, and pyaemia. 

Give the symptoms of acute synovitis. 

Pain, intense, bursting. Worse at night. 

Tenderness. Slightest touch or motion unbearable. 

Swelling. Fluctuates, takes the shape of the synovial sac, and 
appears at certain portions of the joint. (At the sides of the 
quadriceps tendon and beneath the patella, in the knee-joint ; 
at the sides of the olecranon and triceps in the elbow-joint.) 

Muscular atrophy. Inflammatory fever, with local heat and 



If suppuration ensues, these symptoms, both local and con- 
stitutional, are aggravated ; the patient has chills, the fever 
shortly becomes typhoid in type, and the joint becomes red and 
oedematous. 

How do you treat acute synovitis? 

Carefully splint in the position which will leave the most use- 
ful limb should anchylosis occur. (Elbow at right angles, knee 
straight.) Leeches and an ice-bag in the early stages. Aspi- 
rate if the synovial sac becomes greatly distended. Light diet, 
opium to relieve pain, regulate the bowels. 

If suppuration ensues, incise, irrigate, drain, and dress anti- 
septically. Stimulants, tonics, and generous diet. 

Describe chronic synovitis. 

May result from acute. Synovial membrane may become 
thickened and indurated from venous congestion, or pass into a 



DISEASES OF JOINTS. 161 

state of fatty or "pulpy" degeneration. Fluid in the synovial sac 
usually considerable in amount ; clear, or slightly opalescent. 

Muscular atrophy commonly present. Symptoms of inflamma- 
tion slight or wanting. Disability not absolute, joint weak, 
but can be used. 

Give treatment of chronic synovitis. 

Counter-irritation by blisters, or tr. iodin. Pressure by elastic 
bandage. Unguent, hydrarg. cum belladon. locally. Steaming the 
joint. Fixation by means of plaster bandages. Injections of tr. 
iodin. and distilled water, equal parts of each, into the joint. 
Treatment of associated systemic conditions, as rheumatism or 
syphilis. 

Describe hydrarthrosis. 

Hydrarthrosis or hydrops articuli is a serous effusion into a 
joint. It may arise from acute or chronic synovitis, or 
spontaneously. 

Symptoms and treatment as for chronic synovitis. Open and. 
drain if everything else fails. 

Arthritis. 

What is arthritis ? 

Arthritis is an inflammation beginning in either the synovial 
membrane or the bone, and affecting all the structures of a joint. 

What are the varieties of arthritis ? 

Acute. Chronic. Traumatic and infective (pyaemia, gonor- 
rhoea, etc.), usually acute. Diathetic (struma, gout, rheuma- 
tism), frequently chronic. 

What are the symptoms of acute arthritis ? 

Pain. Throbbing, tensile, worse at night. The limb is subject 
to spasmodic startings during sleep, which, from the pain they 
provoke, will cause the patient to wake suddenly with a cry 
( ' ' osteocopic cry " ) . 

Tenderness. Developed to its most extreme extent. 

Swelling. Involves the entire joint area. 

Crepitus. May be felt when the cartilages are eroded. 
11 



162 ESSENTIALS OF SURGERY. 

Preternatural mobility. Although the joint is rigidly fixed by 
the muscles, examination under either will show softening and 
relaxation of ligaments, and the possibility of producing motions 
not normal to the joint. 

Atrophy. Muscles of the affected limb rapidly waste. 

Heat, redness, and oedema. Especially when pus is formed. 

Fever. Ranges high, accompanied by rigors when there is 
suppuration, and quickly passes to the typhoid or the hectic 
type. 

What symptoms distinguish arthritis from synovitis ? 

In arthritis. Starting pains at night. Swelling more diffused 
about the joint and doughy rather than fluctuating. Crepitus. 
Unnatural mobility and atrophy more marked. Constitutional 
symptoms more serious. 

Give the treatment for acute arthritis. 

Absolute rest in a favorable position (splint), with elevation, 
and the application of cold or heat. 

If suppuration ensues, open freely, drain thoroughly, and treat 
antiseptically. 

In some cases of traumatic arthritis, or arthritis secondary to 
acute epiphysitis, amputation may be necessary, if the patient 
steadily fails after opening and draining. 

Constitutional treatment. Stimulants, tonics, and generous 
diet. 

What is the usual cause of acute arthritis in infants ? 

An acute epiphysitis which suppurates, and quickly involves 
the joint. Treatment. Evacuate pus immediately, and splint to 
prevent deformity. 

What is white swelling ? 

White swelling, or gelatinous arthritis, is a strumous inflam- 
mation of a joint, beginning usually as a (tubercular) synovitis, 
and characterized by slow course, with ultimate tendency to 
total disorganization of the part. 

Swelling. Diffuse and somewhat elastic; 

Pain. Gnawing in character, not very acute. 

Color, Usually blanched. 



DISEASES OF JOINTS. 163 

Atrophy. Well marked. 

Preternatural mobility. Keadily detected. 

Impairment, but not loss of function. 

Give the treatment for white swelling. 

1. Absolute rest, by means of fixed dressings kept on for 
months. 

2. Tonics, stimulants, alteratives, cod-liver oil, quinine, iodide 
of iron. 

3. Fresh air and good food in abundance. 



Goxalgia. 

What is coxalgia ? 

Coxalgia is a strumous arthritis of the hip-joint, occurring 
usually in persons under fifteen years of age. It is more 
common in boys than in girls, and is frequently tubercular. 

Name the varieties of coxalgia. 

1. Femoral. The disease begins in the upper epiphysis of 
the femur. 

2. Acetabular. The floor of the acetabulum is first involved. 

3. Arthritic. The disease begins as a synovitis. 

Into what stages may coxalgia be divided ? 

1. Inflammation. Flexion and fixation of joint. 

2. Effusion. Flexion, abduction, and fixation, with apparent 
lengthening from compensatory curvature of the spine. 

3. Frequently suppuration. Flexion, fixation, adduction, and 
inversion. Apparent shortening, due to a compensatory curvature 
of the spine in the opposite direction. Backward luxation of 
femur may take place in this stage. 

What are the early symptoms of hip-joint disease ? 

Pain, frequently referred to knee. 

Tenderness, elicited by jarring the femur upward, or pressing 
suddenly inward upon the trochanter. 

Limping, which may wear off in the evening. 

Fixation, detected by attempting to flex, extend ? and rotate 



164 ESSENTIALS OF SURGERY. 

the femur, when the muscles resist and the pelvis is felt to move 
with the thigh. Place the patient on his back, upon a bed or 
table, and press the knee of the affected side downward till the 
popliteal space touches the supporting surface, the lumbar ver- 
tebrae can be felt arching upwards. Raise the thigh to a right 
angle with the pelvis, the vertebral arch disappears, and on 
further flexion, the pelvis on the affected side is raised from the 
table. 

Flexion. The limb of the affected side is slightly flexed and 
carried in advance of its fellow, the latter bearing the weight of 
the body. 

What symptoms denote the further extension of the disease? 

Second stage. Pain is more intense, with "starts" at night 
(showing exposure of bone by erosion of cartilages). Tenderness, 
limping, and fixation are more marked. Swelling may be per- 
ceptible. Atrophy is apparent ; nates flattened ; gluteo-femoral fold 
less distinct than on the sound side, circumference of thigh and 
leg lessened. Position. Limb flexed, abducted, and everted, 
with pelvis lowered on affected side. Failure in general health. 

Third stage. Position. Flexion, adduction, and inversion, 
the affected thigh crossing the other. Pelvis elevated on the 
diseased side. Shortening, real from wasting, and apparent from 
spinal curvature. Suppuration and abscesses common. Hectic 
with rapid emaciation. 

How may you distinguish between the various forms of cox- 
algia ? 

The arthritic form approaches nearer to the type of an acute 
inflammation, with sharp pain in the hip-joint, swelling, etc. 
The femoral variety is characterized by starting pain most 
marked at the knee (obturator and anterior crural nerves), by 
shortening and luxation as the disease progresses, by abscesses 
pointing to outer part of thigh, below the trochanter. 

Acetabular. Tendency to abscess most marked, may point from 
within the pelvis, over the nates, or above Poupart's ligament. 

What is the prognosis in hip-joint disease? 
Arthritic form is, in children, favorable. Femoral and age- 



DISEASES OP JOINTS. 165 

tabular forms more grave, especially the latter. In adults the 
prognosis is unfavorable. 

What are the complications of hip-joint disease ? 

1. Suppuration. 2. Amyloid degeneration. 3. Tubercular 
meningitis. 

How do you treat hip-joint disease ? 

In light and beginning cases, ^a fixation splint to the affected 
side (Agnew's, Thomas's, or a plaster bandage), a high-soled 
shoe (three inches) on the sound side, and a pair of crutches. 
For more serious cases, rest in bed, with extension apparatus, as in 
fractures, applied to the affected side, and counter-irritation, by 
means of blisters, over the inflamed joint. On disappearance of 
all symptoms get the patient up with high shoe, crutches, and 
splint, which must be continued for one year. 

Constitutional treatment on general principles. Plenty of nour- 
ishing food and fresh air. Stimulants and tonics as required. 
Cod-liver oil and syrup ferri iodidi. Abscesses should be evacuated 
promptly by aspiration, or incision and drainage, under anti- 
septic precautions. 

How do you treat anchylosis in a faulty position, following hip- 
joint disease ? 

By subcutaneous division of the neck of the femur by means 
of a strong narrow saw (Adams's), bringing the thigh into 
good position (extension), and treating as a fractured femur. 

Continuous extension may succeed without an operation, in some 
cases. 

Under what circumstances should the head of the femur be ex- 
cised? 

1. When it is necrosed and detached. 

2. When other treatment has failed to check very free suppu- 
ration and rapid exhaustion of patient. 

3. In some cases of displacement. 

Under what circumstances is amputation justifiable in the 
treatment of hip-joint disease? 

1. When there is extensive disease of the femur and free sup- 
puration. 

2. After excision which has not modified symptoms. 



166 ESSENTIALS OF SURGERY. 

How do you distinguish between psoas abscess and coxalgia ? 

Psoas abscess can be felt as a fluctuating swelling, appearing 
to the outer side of the bloodvessels below Poupart's ligament, 
and traceable, through the abdominal wall, along the course of 
the psoas muscle. On marked flexion the pelvis does not move 
with the femur. Extension gives pain, referred to the loins. 



Sacro-Iliac Disease. 

Describe sacro-iliac disease. 

Sacro-iliac disease is a strumous arthritis of the sacro-iliac 
joint, occurring in early life, and characterized by — 

Pain over the affected joint, aggravated by coughing, strain- 
ing at stool, or by lateral pressure. 

Tenderness and swelling in the region affected. 

Lameness appearing early. 

Lengthening real, from downward displacement of os innomi- 
natum. Suppuration. 

The prognosis is bad. Treatment as in case of hip-joint dis- 
ease. If an abscess threatens to break, incise, remove dead 
bone, asepticize, and drain. 

White Swelling of the Knee-Joint, 

Describe white swelling of the knee-joint. 

White swelling of the knee is usually a strumous (tubercular) 
affection, occurring in children, and characterized by — 

Pain, slight at first, becomes starting. 

Swelling, moderate at first, gradually increasing. 

Tenderness, particularly marked on inner aspect. 

Lameness, not producing entire disabilit) r for some time. 

Displacemeyit. Knee at first flexed, but as ligaments are soft- 
ened and yield, there is a backward displacement and outward 
rotation of the tibia on the femur. 

Crepitus, marked. Undue mobility, in a lateral direction. 



DISEASES OF JOINTS. 167 

Abscesses may form, opening externally, or the joint may be- 
come anchylosed. 

Treatment. Fixation in good position, as for chronic synovitis 
and arthritis. In some cases aspiration and injection with a 10 
per cent, emulsion of iodoform in sterile olive oil. In some 
cases erasion, in some resection, in some amputation. 

Rheumatoid Arthritis. 

Describe rheumatoid arthritis (osteo-arthritis). 

Seats. 1. Hip. 2. Shoulder. 3. Jaw. 

Lesions. Absorption of cartilage, ulceration of bone surfaces 
with rarefaction, shortening of ligaments, and bony deposits in 
and around the joint. Occurs after middle life, usually in men. 

Symptoms. Frequently bilateral ; disability, some deformity, 
crackling, and atrophy. 

Treatment. Local support, quinia, and general hygiene. 

Loose Bodies in Joints. 

What are the causes of loose bodies in a joint ? 

1. From altered blood-clot (fibrinous). 

2. From hemorrhage into a synovial fringe, which subse- 
quently organizes and is loosened. 

3. From the gradual detachment of a synovial fringe. 

4. In rheumatoid arthritis synovial fringes may be converted 
into cartilage, and become pediculated or loosened, or the nodular 
masses about the joint may project into the articular cavity. 

5. As the result of injury, a portion of cartilage may be either 
chipped off or may, by a process of necrosis, be shed into the 
joint. 

Knee-joint usually affected. 

Give the symptoms of loose bodies in a joint. 

Becurrence of attacks characterized by — 

Sadden, agonizing pain, and fixation of the joint in slight flexion, 
followed by synovitis. 

Detection of the body by manipulation ; commonly found in the 
pouch over the external condyle of the femur. 



168 ESSENTIALS OF SURGERY. 

How do you treat loose bodies in joints ? 

Radical. Secure the body in place by transfixing it with a 
strong needle ; dissect it out, checking bleeding before opening 
the joint. If it has a pedicle, ligate. Close the wound, dress, 
and immobilize. 

Palliative. Knee-cap. 



Anchylosis. 

What are the varieties of anchylosis or stiff joint ? 

True anchylosis is dependent on articular and intra-articular 
thickening and adhesions. True anchylosis may be complete, in 
which case the articular surfaces are united in part or through- 
out by bone. Rarely found except after traumatic arthritis. 

Or it may he incomplete, motion being restricted by fibrous 
union between the joint surfaces, and thickening of the capsule. 

False anchylosis is dependent on contractions and adhesions of 
the soft parts around the joints. 

The Rontgen rays are useful in diagnosis of the exact condi- 
tion. 

Give the treatment of anchylosis. 

Incomplete or fibrous anchylosis. Passive motion, employment 
of hot-air apparatus, and use of the part. Application of 
splints, the angle of which can be changed. Continuous exten- 
sion by means of weights. Forcible flexion and extension 
under anaesthetics. 

Complete or bony anchylosis. If the position is good, let alone, 
except in the case of the elbow, which should be excised. If 
the position is bad, osteotomy or resection. 



DISEASES OF BONES. 169 



DISEASES OF BONES. 



Name the inflammatory diseases of the bones. 

Periostitis, osteitis, osteomyelitis, epiphysitis. 



Periostitis. 

Describe periostitis. 

1. Simple local periostitis, which may become suppurative peri- 
ostitis, forming periosteal abscess. 

2. Diffuse infective periostitis. 

(1) Local periostitis. Cause. Local injury or extension of in- 
flammation from other parts. 

Pathology. Thickening of external fibrous layer, prolifera- 
tion of inner osteogenetic layer, and inflammatory exudate 
loosening the periosteum from the bone. It may terminate in : 
1. Resolution. 2. Periosteal abscess. 3. Periosteal nodes (par- 
ticularly in chronic periostitis). 

Symptoms. Pain. Intense, bursting, and worse at night. 

Swelling of soft parts overlying. 

Tenderness. Well marked on pressure. Fever. 

In suppuration, symptoms are increased in severity ; there are 
oedema, and discoloration of skin. 

Treatment. Rest in bed, elevation, cold, opium for pain, 
leeches. Should pain and fever be unabated, or increase in 
twenty-four hours, free incision. If pus, open. For osteoplastic 
periostitis (periosteal nodes), oleate of mercury, subcutaneous 
section, or ablation by gouging. 

(2) Diffuse infective periostitis. 

Cause. Injury to a strumous subject. 

Seat. Long bones ; femur, tibia, humerus. 

Pathology. Rapid septic suppuration, completely separating 
periosteum from bone. 

Symptoms. High fever and profound constitutional disturbance 
rapidly running to a condition of septicaemia. 



170 ESSENTIALS OE SURGERY. 

Deep-seated pain. Bedness, puffiness, and oedema of the skin 
appear early. 

Treatment. Early and free incisions. Antiseptic irrigation. 
Thorough drainage. Stimulants, tonics, and rich diet. 

Osteitis. 

Describe osteitis. 

Cause. Injury, diathesis (scrofula, syphilis, rheumatism). 

Pathology. Inflammatory exudation and cellular hyperplasia in 
the Haversian canals, with solution and removal of the bone sub- 
stance. Haversian canals, lacunae, canaliculi become widened, 
and may disappear by coalescence. This constitutes rarefying 
osteitis or osteoporosis. The bones may yield to pressure and be- 
come greatly deformed, constituting osteitis deformans. If the 
inflammation is very acute, rapid proliferation causes strangu- 
lation of vessels and the bone dies in mass (necrosis), or by 
molecular death and discharge (caries). If inflammation is 
somewhat chronic, the absorbed bone is replaced by a new de- 
posit, excessive in amount, and very dense (osteosclerosis or 
osteoplastic osteitis), or the inflammation may result in a local- 
ized collection of pus (abscess of bone). 

Symptoms. As in periostitis. Osteocopic (starting) pains 
more marked. Tenderness on tapping. (Tenderness on pres- 
sure greatest in periostitis.) Limb heavier and more useless. 

Treatment. As for periostitis. Hot fomentations of lead 
water and laudanum. Subcutaneous drilling. Trephine. Treat 
diathesis. 

Osteomyelitis, 

Describe osteomyelitis. 

Definition. Inflammation of the marrow of the bone. 

Cause. Traumatism. May occur primarily, or may be sec- 
ondary to other affections of the bone. 

Varieties. 1. Simple. 2. Suppurative. 3. Gangrenous. 

1. Simple osteomyelitis. There is proliferation affecting the 
embryonic cells in the medulla and in the surrounding Haversian 



DISEASES OF BONES. 171 

canals and cancellous tissue, the fat disappears, the bone is 
absorbed. Granulation tissue is formed which may undergo 
resolution, may organize into bone filling the medullary canal (as 
in case of fractures), or may suppurate. 

2. Suppurative osteomyelitis. May be circumscribed forming 
bone abscess, or diffuse, leading to extensive necrosis or pyaemia. 

3. Gangrenous osteomyelitis. Due to a very high grade of in- 
flammatory action, causing death by obstruction to circulation. 

Complications of osteomyelitis. Caries, or bone ulceration. Ne- 
crosis, death of bone ; this may be central, involving the inner 
laminse only ,. peripheral, involving the outer laminae, or total, 
involving the whole thickness of the shaft. Separation of epiphy- 
sis. Inflammation of epiphysis. Pyarthrosis. Pycemia. 

Osteomyelitis exhibits a tendency to spread towards the trunk. 

Treatment. Simple osteomyelitis, as for osteitis. 

Suppurative osteomyelitis. Open with trephine, chisel, or gouge. 
If suppuration is extensive and associated with pyarthrosis (pus 
in joint), amputate. 

Gangrenous osteomyelitis. Amputate. 

Abscess of Bone. 

Describe abscess of bone. 

Nature. Usually strumous. 

Cause. Due to rarefying osteitis, or the breaking-up of case- 
ated tubercular masses. 

Seat. Head of tibia usually (Brodie's abscess). 

Symptoms. Boring persistent pain, worse at night. Tender- 
ness especially marked on striking or tapping. 

Treatment. Apply a rubber bandage and tourniquet and 
search for pus with a drill. Trephine ; scrape, and chisel out 
all rough or carious bone. Pack with iodoform gauze, apply an 
antiseptic dressing and a splint. 



172 ESSENTIALS OF SURGERY. 

Caries. 

Describe caries. 

Definition. Ulceration or molecular death of osseous tissue. 

Pathology. As for rarefying osteitis. The surrounding bone 
is indurated, except in struma, when it is converted into a 
mass of fungous granulations. 

Seats. Cancellated extremities of long bones. Often affects 
the joints secondarily. 

Symptoms. Those of osteitis with abscess. 

On probing, the softened, roughened, readily bleeding diseased 
area is detected. The discharge contains an excess of phosphate 
of lime. 

Treatment. Kemove the diseased bone by the curette, gouge, 
or osteotrite. When the detritus preserves its color in spite of 
washing, sound tissue is reached. Excision or amputation may 
be necessary. 

Necrosis. 

Describe necrosis. 

Definition. Death of bone in mass. 

Direct cause. Osteitis in any of its varieties. 

Bemote cause. Scrofula, syphilis, phosphorus, exposure to 
heat and cold, etc. 

Necrosis may be dry (the ordinary variety), due to inflam- 
matory strangulation, or moist, due to sudden death from injury. 

Necrosed bone is dry, dirty yellow or brown, hard, and does 
not bleed when struck with a probe. When loosened it is 
thrown off as an exfoliation. The periosteum frequently retains 
its vitality, and throws out a sheath of new bone surrounding 
the dead portion, which, when it is entirely separated from the 
living bone and thus surrounded, forms a sequestrum, and is 
said to be invaginated. The sheath of bone investing the seques- 
trum is called the involucrum. The openings in the involucrum, 
through which the discharge makes its way to the surface, are 
called cloacae. Dead bone is separated from the living by a 
process of granulation. 



DISEASES OF BONES. 173 

Sequestrum. Dead bone surrounded by living bone. 

Involucrum. A shell of living bone surrounding a sequestrum. 

Cloacae. Openings in an involucrum. 

Symptoms. Those of bone inflammation, followed by free sup- 
puration, with discharge of laudable pus ; this continues for a 
long time, the abscess openings contracting down to sinuses. 

Diagnosis. Made by feeling the hard, rough surface of dead 
bone with a probe. 

Treatment. Nourishing food, tonics, fresh air, iodide of iron, 
and cod-liver oil. Sequestrotomy when the sequestrum is loose. 
In some cases close the bone cavity by a moist blood clot or 
Senn's bone chips. 

Tubercle. 

Describe tubercle of bone. 

Three forms. Miliary tubercle, caseating tubercle, and scrofulous 
osteitis (chronic rarefying osteitis). May be local (encysted) or 
diffuse (infiltrated) ; more commonly the latter. 

Seal. Cancellated ends of long bones. 

Common form. Scrofulous osteitis (tubercular nature cannot 
always be proven) ; occurs chiefly on hands, feet (strumous dac- 
tylitis), ends of long bones (abscess, or scrofulous arthritis), and 
bodies of vertebrae, (Pott's disease). 

Symptoms. Those of osteitis, together with the signs of scrofu- 
lous diathesis. 

Treatment. Air, good food, general hygiene, etc. 

Counter-irritation, pressure,, and splinting. When suppura- 
tion takes place, open, and remove entire disease area. 

Syphilitic Bone Disease. 

Describe the osseous lesions of syphilis. 

Acquired. Gummata between periosteum and bone, forming 
periosteal nodes. These nodes chiefly affect the tibia, ulna, 
clavicle, and hard palate. Rarely, a diffused chronic form of in- 
flammation causes syphilitic osteitis or sclerosis. 

Congenital, In very young children cranio tabes, or wasting 



174 ESSENTIALS OF SURGERY. 

of bone at the sites of decubitus, i. e., behind the eminences of 
the parietal bones. Alterations in the epiphyseal cartilage making 
the bone brittle and soft, Hutchinson'' s teeth, and Parrot's nodes or 
osteophytes, appearing in the form of bony projections about the 
anterior fontanelle, and on the tibia and humerus. 

Osteomalacia. 

Describe mollities ossium or osteomalacia. 

A disease characterized by general softening of the bones, ren- 
dering them liable to be bent or broken. 

Occurs during and after adult life, mostly in females. 

Pathology. Rarefaction and absorption of bone, advancing 
from the centre outward. Replacement of medullary tissue by a 
dark-red, semi-fluid material. 

Symptoms. Obscure pain in the bones and malaise. Phos- 
phates in the urine. Fractures, deformity. 

What is fragilitas ossium ? 
A brittleness of bone dependent on fatty degeneration. 



Pott's Disease. 

What is Pott's disease? 

Pott's disease is an angular deformity of the spine caused by 
caries of the vertebrae or the intervertebral cartilages. 

Give the pathology of Pott's disease. 

Usually due to a tubercular osteitis which affects the bodies 
of several vertebrae simultaneously ; these becoming softened, 
yield to the superimposed weight, thus causing deformity. There 
may be no pus formation, the inflamed area being removed 
by interstitial absorption, the pus may become encysted and 
caseated, or, more commonly, may appear as a cofa? abscess. The 
cord is rarely injured, the deformity being so gradual that it ac- 
commodates itself to its new course. 

Anchylosis, which is a reparative effort, goes hand in hand 
with the disease, new bony arches being thrown out between the 



DISEASES OF BONES. 175 

vertebrae. Pott's disease occurs most frequently in childhood, 
and is commonly found in the dorsal and cervical regions. 

Give the symptoms of Pott's disease. 

1. General failure in health. 

2. Rigidity of spine. Detected by getting the patient to pick 
an object from the floor, to rise from a dorsal recumbent posture, 
or. to turn from the back to the belly. In consequence of rigidity 
and tenderness, the gait is tottering, shuffling, and uncertain. 

3. Pain and tenderness, elicited at times by jarring the head 
or by inducing the patient to jump from a chair or step. May be 
found by direct pressure. There is a constant tendency to sup- 
port the back ; the patient will frequently lie down, or, if sitting, 
will support the weight of the shoulders on the thighs. 

4. Reflex irritation. Lumbar disease is frequently attended 
with colicky pain, irritation of the bladder, and incontinence of 
urine. Dorsal disease is characterized at times by a grunting 
respiration. Cervical disease may cause torticollis, choreic move- 
ments of the neck muscles, or difficulty in deglutition. 

5. Deformity. Undue prominence of spinous process causing 
a backward projection. 

6. Abscesses. 

7. Paresis or paralysis. 

In what directions do the abscesses of Pott's disease point? 

Cervical region. Post-pharyngeal abscess may be formed, or 
the pus may pass outward between the longus colli and scaleni 
muscles, appearing behind the sterno-cleido-mastoid, or it may 
pass downward. 

Dorsal region. Pus may pass directly backward, or form 
psoas, iliac, or lumbar abscess. 

Lumbar region. Lumbar abscess, appearing to outer side of 
quadratus lumborum. Psoas or iliac abscess. 

Give the treatment of Pott's disease. 

Constitutional, as for strumous affections. 

Local. Best. In the early stages rest in bed. Plaster jacket 
with either entire or partial confinement to bed. 

Abscesses must be opened asepticatly as soon as detected. Open 
psoas abscesses above Poupart's ligament before they are per- 



176 ESSENTIALS OF SURGERY. 

ceptible in the groin. Some surgeons also make an incision in 
the back and remove the dead bone. 

How is the plaster jacket applied ? 

Bandages two and one-half or three inches wide, seven yards 
long, made of gauze, mull, or crinoline. Rub dry plaster of Paris 
thoroughly in the meshes of each bandage as it is rolled. Place 
on the patient a clean thin summer undershirt, pad all bony 
projections with cotton, put over the abdomen next to the skin 
a "dinner pad" (a folded towel), suspend the patient by the 
head and shoulders, wet the bandages, and apply them so that 
the expanded basin of the pelvis is caught below and the sup- 
port comes well up beneath the axilla of each side. Remove 
the dinner pad when the bandage hardens. 

The treatment of forcible correction of the deformity and 
application of plaster-of- Paris finds a number of advocates. 

Rickets. 
Define rickets. 

Rickets is a constitutional disease of childhood, characterized 
by lesions of the osseous system, and a tendency to amyloid de- 
generation of the viscera. 

Etiology, defective or unsuitable food. 

Give the pathology of rickets. 

Increased cell-growth, with deficiency of earthy matter. En- 
largement of epiphyseal cartilages. Thickening of periosteum. 
Softening and distortion of the shafts of the bones. 

Give the symptoms of rickets. 

Premonitory. Delayed dentition, restlessness at night, sweating 
about the head, abundant urine loaded with phosphates. 
Of the developed disease. Deformities. Such as — 

1. Pigeon-breast, with beaded ribs from enlargement of costo- 
chondral junction. 

2. Lateral or antero-posterior curvatures of the spine. 

3. Bent legs or arms with rounded enlargements at the ends of 
the long bones. 

As a frequent complication we have bronchitis, serious on ac- 
count of the yielding nature of the chest walls. 



CURVATURE OF THE SPINE. 177 

Treatment. General hygiene, nourishing diet, cod-liver oil, 
lactophosphate of lime, iron, sj^rup. hypophos. comp. 

Haemophilia. 

Describe haemophilia. 

Haemophilia is a congenital and habitual hemorrhagic dia- 
thesis, in virtue of which persistent bleeding may occur, of it- 
self, or from the slightest wound. 

Treatment. Compresses saturated in Monsel's solution ; local 
application of a 10 per cent, solution of gelatin in normal salt 
solution ; elevation of part ; strong pressure, ergot, acetate of 
lead, or chloride of calcium internally. 

Struma. 

What is struma? 

Struma or scrofulais a defective bodily condition characterized 
by a tendency to the development of chronic (tubercular) inflam- 
mations of the bones, joints, and lymphatic glands. 

What are the characteristics of scrofulous inflammations ? 

1. They develop at an early period in life. 

2. They are chronic in type. 

3. They occur chiefly in phthisical families. 

4. They exhibit a marked tendency to pass on to suppuration 
and caseation. 

5. They are prone to appear in certain regions. Example, 
cervical adenitis. 

Give the treatment of scrofulous inflammation. 

Constitutional. Generous diet, fresh air and sunshine, cod- 
liver oil, iodide of iron. 

Local. Active counter-irritation, pressure, operative pro- 
cedures. 

Curvature of the Spine. 

Describe spinal curvature. 

The curvature may have its convexity directed forward, back- 
ward, or to the side. 
12 



178 ESSENTIALS OF SURGERY. 

The cause of curvature is long-continued, unequal compression 
of the intervertebral cartilages. 

Forward curvature, or lordosis, is usually found in the lumbar 
region, and is simply an exaggeration of the normal curve, com- 
pensatory to some deformity or diseased condition, such as 
ricket, congenital femoral luxation, coxalgia, etc. 

Backward curvature, or kyphosis, usually appears as an exagge^ 
ration of the normal dorsal curve. It is the result of debility, 
rickets, or occupation requiring constant stooping. 

Treatment. In the young, friction, massage, deep breathing, 
exercises for back muscles, braces which are comfortable only 
when the shoulders are held back. 

Lateral curvature, or scoliosis, develops most frequently in 
girls, between the ages of 14 and 18. There are usually two 
curves with their convexities turned in opposite directions. The 
vertebrae are rotated on their vertical axes, their spinous pro- 
cesses pointing towards the concavity of the curves. 

Causes. Inequality in the length or strength of the legs; one- 
sided position or use of the body ; contractions following em- 
pyema or paralysis of spinal muscles of one side. These causes 
are rendered more operative by debility, or a strumous or rachitic 
diathesis. 

Symptoms. Sense of fatigue and pain in back and shoulder 
when sitting, or on first lying down. Wing-like projection of 
scapula (dorsal curvature is usually toward right), and undue 
prominence of the iliac crest of the affected side, with projection 
of the breast on the opposite side. Curvature may be detected 
by marking the spinous processes, though it must be remembered 
that the amount of deformity is much greater than is indicated 
by this test. 

Treatment. Change in habits or occupations which can act as 
exciting causes. Massage, friction, and electricity to the mus- 
cles of the back, systematic gymnastic exercises, suspension fol- 
lowed by rest in the recumbent position. If deformity increases, 
it may be necessary to apply a plaster-jacket. 



HERNIA. 179 

HERNIA. 

What is a hernia? 

The protrusion of a viscus through an abnormal opening in the 
walls of the cavity in which it is contained. 

As applied, hernia is synonymous with rupture, and indicates 
protrusion of the abdominal viscera through abnormal openings 
in the parietes. 

What are the essential parts of a hernia ? 
1. The sac. 2. The contents. 

Describe the sac. 

The sac may be (1) congenital. Found only in umbilical and 
inguinal regions ; consisting of a pouch of peritoneum ready to 
receive the hernia. (2) Acquired. Developed by gradual stretch- 
ing of the parietal peritoneum. This is the form of sac ordinarily 
found. 

The formation of the sac. Pressure of abdominal contents upon 
the parietal peritoneum may cause a bulging of the membrane 
where it is poorly supported, as at the internal inguinal ring ; the 
peritoneum yields, and the bulging is developed into a pouch 
which fills the inguinal canal ; escaping from the external ring 
its base is less supported, and it forms a pyriform swelling, con- 
sisting of— (1) The neck, at the internal ring. (2) The body, the 
main part of the sac. (3) The fundus, or wide extremity. As 
the peritoneum is dragged downward it becomes puckered at the 
neck. 

During the stage of (1) Formation, this puckered neck exerts 
no constriction upon the hernial contents. 

Stage 2. Organization. These puckerings become adherent, 
and the surrounding subserous fat is indurated. 

Stage 3. Contraction. The neck of the sac contracts and may 
become obliterated, or may cause strangulation if the gut be 
protruding. 

The sac, at first smooth, becomes thickened, contracts, adheres, 
and is irreducible ; at times it sends off diverticula or secondary 
sacs. * 



180 ESSENTIALS OF SURGERY. 

How are hernias classified in regard to the contents of the sac? 

1. Epiplocele. Containing omentum only, most common on 
left side. 

2. Enterocele. Containing intestine only, usually ileum. 

3. Entero-epiplocele. Containing both omentum and gut. 
Further we may have cystocele (bladder), ccccocele (caecum), gas- 

trocele, etc. 

What are the causes of hernia ? 

1. Predisposing, Stec, males. Heredity. Age, young. Length- 
ened mesentery. Structural defects (congenital). Occupation. 
Abnormal conditions, such as a protracted cough, operations on 
the abdomen, and muscular relaxation. 

2. Exciting. Muscular contraction. 

What are the common seats of hernia ? 
In the inguinal, femoral, and umbilical regions. 

What are the varieties of hernia in regard to their condition ? 

(Clinical varieties.) 

1. Beducible. Most common form, the contents can readily 
be returned into the abdomen. 

2. Irreducible. Contents cannot be reduced into abdomen. 

3. Obstructed or incarcerated. The contained bowel becomes 
obstructed by its contents. 

4. Inflamed. There is inflammation or localized peritonitis 
of sac and contents. 

5. Strangulated. Subject to a constriction not only obstruct- 
ing the bowel, but seriously interfering with its circulation. 

Reducible Hernia. 

What are the symptoms of reducible hernia? 

1. Enterocele. A smooth, regular, round tumor in a hernial 
region, often to be traced through the hernial canal, larger on 
standing than on lying down. Tympanitic on percussion, gurgles 
when manipulated. Disappears with a flap when pressed inwards. 
Presents succession (an expansile push) on coughing. Local 
weakness, dragging pains, and irregular dyspepsia. 



HERNIA. 181 

2. Epiplocele. No tympanites, no flop, no gurgle ; the symp- 
toms the same but less marked. Doughy and uneven on palpa- 
tion. 

Give the treatment for reducible hernia. 

1. Palliative. 2. Radical. 

Palliative. Truss, consisting of pad and spring. Pad must 
be slightly convex, and large enough to cover the external open- 
ing and the canal through which the hernia descends. The 
spring must so act on the pad that the pressure is just sufficient 
to keep the hernia up. 

To test a truss, let the patient stoop, cross the legs, and cough, 
sitting on the edge of a chair with the body leaning forward 
and legs widely separated. 

To measure for a truss. (Inguinal or femoral.) From lower 
border of hernial opening to the anterior superior spine of 
ilium of same side, from this point around the body one inch 
below crest of ilium to other iliac spine, thence to upper part of 
hernial opening. 

Directions for use. Immediately remove truss if hernia should 
come down. Bathe the skin beneath the pad with whiskey and 
alum on taking off the truss, and before replacing it. Take off 
after lying down and replace before rising. 

Radical cures. The various operations devised for this pur- 
pose have in view : 1. Obliteration of the neck of the sac either by 
ligature, or stitches, or by plugging it with the invaginated 
fundus. 2. The obliteration of the canal ; and 3. The closure of 
the external and internal rings. Bassini's operation for inguinal 
hernia makes a new canal by transplanting the cord to just 
below the external oblique muscle. In Halsted's operation the 
cord is placed between the skin and the external oblique muscle. 

Irreducible Hernia. 

What are the causes of irreducible hernia? 

Temporarily irreducible, from slight distension with faeces or 
gas. 
Permanently irreducible, from the bulk of the tumor, constric- 



182 ESSENTIALS OE SURGERY. 

tion of the neck of the sac, adhesions within the sac, fatty 
enlargement of prolapsed omentum. 

How do you treat irreducible hernia ? 

Temporarily irreducible, as for incarcerated. 

Permanently irreducible. If very large, apply a bag truss, if 
moderate in size, fit a truss with a concave pad ; advising, in all 
cases where there is pain or discomfort, an operation for the 
radical cure of the hernia. 



Incarcerated Hernia. 

What are the symptoms of obstructed or incarcerated hernia ? 

Occurs mostly in irreducible hernia, particularly in such as con- 
tain colon. Constipation is a strong predisposing factor. 

1. Tumor is enlarged and slightly tender. Liquid and gaseous 
contents may be pressed out, and doughy faeces detected. 

2. There is some pain, -with distension of the stomach, constipa- 
tion, nausea, and vomiting. 

3. The constitutional symptoms are of moderate severity. 

4. There is impulse on coughing. 

How do you treat incarcerated hernia? 

Treatment. Eest in bed, cracked ice by the mouth, complete 
relaxation oy position. Apply an ice-bag to the hernia, and 
give opium if there is pain. Open the bowels by purgative ene- 
mata, followed by castor oil as soon as the tumor is diminished in 
size. If symptoms of obstruction persist, perform herniotomy. 

Inflamed Hernia. 

Describe inflamed hernia. 

Cause. Injury to a small irreducible hernia, usually inflicted 
by a badly fitting truss. 

Symptoms. Chiefly those of acute local inflammation. Bed- 
ness, heat, pain, swelling (nodulated if epiplocele, sac contains 
fluid if enterocele), impulse on coughing. Fever, vomiting, and 
constipation of moderate severity. Wind passed by bowels. 

Treatment. Opium if great pain. Rest in bed with local 



HERNIA. 183 

relaxation by position. Ice-bag to the inflamed part. Opening 
enema (soap and water Ojss). Gentle purgation when inflam- 
mation subsides. 



Strangulated Hernia. 

What are the causes of strangulated hernia? 

1. Sudden descent into the sac of an irreducible hernia of an 
additional mass of omentum or intestine. 

2. Sudden descent of a hernia long retained by a truss. 

3. Parietal constriction about the opening of a hernia suddenly 
produced by violent effort. 

Where is the seat of constriction ? 

1. At the neck of the sac. At times in the body of the sac, 
from hour-glass constriction. 

2. Entirely within the sac. Due to bands of lymph, or a rent 
in the omentum. 

3. Entirely without the sac. In small hernia suddenly pro- 
duced by violent effort. 

What changes take place in strangulated hernia? 

Bowel is grooved by constriction, becomes oedematous, ecchy- 
mosed, red deepening into purple, loses its lustre, becomes harsh, 
sticky, non-elastic, and dirty black. 

Sign of local death — loss of lustre and elasticity. 

May rupture into the sac, or at the line of constriction. In- 
flammatory adhesions mostly prevent faecal extravasation into 
the peritoneal cavity. 

Sac, attacked by inflammation, effuses serum. 

What are the symptoms of strangulated hernia ? 

1. Tumor becomes more tense, somewhat duller on percussion, 
tender at the neck of the sac, and gives no succussion on coughing. 

2. Abdominal pain, with sense of constriction about umbilicus. 

3. Vomiting, frequent and persistent; first, contents of stomach, 
then bile, finally faeces. 

4. Obstinate constipation. 




184 ESSENTIALS OF SURGERY. 

5. Rapid loss of strength; small, rapid, compressible pulse; dry, 
brown tongue. Very little urine passed, it may contain albumen 
and indican, and be deficient in chlorides. 

Gangrene is denoted by cessation of pain and vomiting, and rapid 
development of symptoms of collapse. 

What is Littre's hernia? 
A hernia involving only a portion of the circumference of the 
bowel. Though the pouch is strangulated, 
there is not absolute internal obstruction. 

What are the symptoms of Littre's hernia ? 

As for strangulated hernia, but less marked; 
vomiting not stercoraceous, constipation not 
absolute. Tumor is small, and gangrene rap- 
idly develops ; hence the treatment is early 
Littre's hernia. herniotomy. 

What are the principal points in the diagnosis of strangulated 
hernia? 

1. Stercoraceous and persistent vomiting. 

2. Absolute constipation. 

3. Great constitutional depression. 

4. Absence of succussion, or impulse on coughing. 

How do you treat strangulated hernia ? 

Rest. Relaxation of parts by position. Taxis. Herniotomy. 

How do you employ taxis? 

Anaesthetize, and fully relax by position (flexion and adduction 
of thigh for femoral or inguinal hernia). The head and shoulders 
should be low, the pelvis elevated. Define the neck of the sac 
with the thumb and forefinger of the left hand, then with the 
fingers of the right hand draw the sac down a little, and by a 
kneading, rolling, compressing movement press the gut in a di- 
rection corresponding to its line of the descent. 

In oblique inguinal hernia the pressure must be outwards, up- 
wards, backwards. 

In femoral hernia first slightly downwards till falciform pro- 
cess is cleared, then directly backwards towards pubic spine. 

Taxis failing in five to eight minutes, perform herniotomy. 



HERNIA. 



185 



Under what circumstances must taxis be avoided ? 

1. Very acute cases, as in hernia of sudden development, from 
violent muscular action. 

2. Where symptoms of strangulation have existed for several 
days. 

3. Where the strangulated gut was previously irreducible. 

4. Where the gut is gangrenous. 

What accidents may occur in the employment of taxis? 

1. Reduction en masse or en bloc. The hernia, together with its 
sac, is pushed directly inward, the strangulation being in no way 
relieved. Denoted by slow, clif- 



Fig. 41. 



Fig. 42. 




Reduction en 
bloc. 



Reduction en 



ficult, forcible reduction not ac- 
companied by gurgle or flop, 
and by persistence of symptoms. 

2. Reduction en bissac. The 
bowel is pressed into a congeni- 
tal diverticulum or pouch, run- 
ning from the body of the sac 
below or beneath the abdominal 
muscles. Symptoms the same 
as reduction en bloc. 

3. Reduction through a rup- 
ture in the neck of the sac, the 

hernia escaping into the subserous cellular tissue. 

These three forms are usually classed as reduction en bloc. 
Treatment. Cut down, secure the sac, open it, and divide the 
constriction at the neck. 

4. Bupture of intestine. Rapid collapse, no gurgle. 

Under what circumstances may symptoms persist after complete 
reduction? 

1. Paralysis of bowel. 

2. Internal strangulation (causes within sac). 

3. Acute peritonitis. 

What treatment should follow reduction by taxis ? 

Compress and bandage locally. Absolute rest, milk diet ; opium 



186 ESSENTIALS OF SURGERY. 

to quiet pain. If no inflammatory symptoms, open bowels by 
castor oil or purgative enemata the fifth day. 

What treatment should follow continuance of symptoms after 
reduction? 

Exploratory laparotomy, and careful search for causes of ob- 
struction. 

Describe herniotomy. 

Empty bladder and rectum. The antiseptic method must be 
carried out to its minutest details. Shave the seat of operation, 
pinch up a fold of skin and transfix, cutting outward and making 
an incision about three inches long. Divide the successive layers 
of tissue on a grooved director till the sac is reached. The sac is 
tense, rounded, bluish, with arborescent vessels. Pinch up a small 
portion with forceps, and notch ; a straw-colored or blood-stained 
serum escapes. Open freely with scissors, pass the finger up to 
the seat of constriction, slip the nail under the resisting band, 
pass a probe-pointed hernia knife along the finger, turn the edge 
forward, and divide the stricture. If the gut is in good condi- 
tion, return ; then restore the mesentery, and sew across the neck 
of the sac, removing its body, or do a formal radical operation. 
Insert a drainage-tube, close the external wound, and apply 
antiseptic dressing, compress, and bandage. 

No fo6d for twenty-four hours, then milk diet. Enema in 
two days. 

How should the intestine be managed? 

Return if it be smooth, glistening, and elastic, even though there 
be great discoloration and ecchymosis. Draw down a little more 
of the gut and inspect the line of constriction before returning. 
This is a common seat of perforation. 

All manipulations must be practised with great gentleness. 

A dull black, sodden, sticky bowel is beyond hope of recovery 
and must not be returned. 

How do you treat gangrenous bowel? 

If the condition of the patient justifies it, resect the gangren- 
ous portion of the intestine, do an anastomosis, and return the 



HERNIA. 187 

bowel. If the patient's condition is critical, it is best to make an 
artificial anus, which can be closed by a subsequent operation. 
If only a limited portion of the bowel is gangrenous, excise, 
and unite the healthy tissue with Czeryiy\s suture, the first row 
including only the edge of the serous membrane, the second 
(Lembert's) starting one-half inch from the edge of the wound, 
and including a quarter of an inch of all the coats of the bowels 
except the mucous membrane. 

How do you treat a faecal fistula or an artificial anus ? 

The faecal fistula frequently closes spontaneously ; if not, a 
plastic operation may be performed, or it may be treated as an 
artificial anus. 

In artificial anus the spur or partition formed by the anterior 
projection of the posterior wall of the bowel may be ulcerated 
through by means of Dupuytren's enterotome, after which the 
external opening may be closed by a plastic operation; or the 
intestine may be detached from the abdominal w T all, drawn out, 
freshened, and united by Czerny's suture. Prepare by twenty- 
four hours' light diet, and thorough washing out of the bowels. 

How should the omentum be managed? 

If acutely strangulated, clamp, excise, secure the bleeding 
points, and return the stump to the abdominal cavity. If ad- 
herent, excise. Omentum must not be left in the sac. 

How do you treat adhesions? 

Break down recent adhesions. Apply two ligatures, and cut 
between old vascular adhesions. 

How do you treat the sac ? 

Dissect it out, suture across the neck, and excise below the 
suture line. 

What is the after treatment ? 

No food for thirty-six hours. Morphia hypodermically for 
pain. Stimulants, if necessary, by the rectum. Open bowels by 
an enema the seventh day. Eemove the drainage-tube in forty- 
eight hours, the sutures on the fourth day. Keep up firm pres- 
sure by means of bandages. In one month apply a truss and 
get the patient out of bed. 



188 



ESSENTIALS OF SURGERY, 



Special Hernias. 

What are the varieties of hernia in regard to position ? 

Diaphragmatic, Inguinal, Femoral, 

Epigastric, Obturator, Lumbar, Perineal, 

Yentral, Umbilical, Ischiatic, Pudendal. 



Fig. 43. 



Inguinal Hernia. 

What is the most common variety of hernia? 

Inguinal hernia. 

Name the varieties of inguinal hernia? 
1. Acquired. 

Complete. When the hernia has passed through the external 
ring. 

Incomplete. When the hernia is still in the inguinal canal, 
called also Bubonocele. 

Oblique. Commonest variety. 
The hernia passes to the outer side 
of the epigastric artery, and if com- 
plete, through the two rings and the 
canal. 

Direct. The hernia passes to the 
inner side of the epigastric artery 
and through the external abdominal 
ring only. 

Further, a complete inguinal 
hernia reaching the scrotum is 
called scrotal, or the labium, in 
woman, is termed labial. 
Rarer forms, depending upon congenital defects, are — 
1. Congenital hernia. In this the peritoneal process (vaginal 
process), accompanying the testis in its descent, remains an 
open pouch and receives the gut. 




Inguinal hernia. 



HERNIA. 



189 



Fig. 45. 




Fig. 46. 



Fig. 47. 




2. Hernia into the funicular Fig. 44. 
portion of the vaginal process (in- 
fantile hernia). This implies the 
same condition as before, ex- 
cept that the proper tunic of 
the testis has become closed, 
the funicular (cord) portion of 
the process alone remaining 
patulous. 

3. Encysted hernia. The ven- 
tricular orifice of the peritoneal 
pouch is closed, the funicular 
and testicular parts remaining 
open. This hernia is of gradual 
formation. It invaginates the 
existing pouch and carries an 

additional layer of peritoneum Encysted hernia, 

with it, making three layers of 

serous membrane to be cut through. 

Describe the inguinal canal. 

The inguinal canal is an oblique passage through the anterior 
abdominal wall, lying parallel to Poupart's ligament and above 
it. It begins at the internal ring, ends at the external ring, and 
is one and one-half inches long. It transmits the spermatic 
cord in man, the rounded ligament in woman. It is bounded — 

In front, by the external oblique, internal oblique (outer 
third), cremaster muscles. 

Behind, by the conjoined tendon (inner third), transversalis 
fascia, triangular ligament, sub-peritoneal tissue, deep epigastric 
artery, and peritoneum. 

Above, by the arch made by the internal oblique and trans- 
versalis. 

Below, by Poupart's ligament and the transversalis fascia. 

Describe the internal abdominal ring. 

The internal abdominal ring is an oval opening situated in 
the transversalis fascia, one-half inch above the middle of Pou- 



190 ESSENTIALS OF SURGERY. 

part's ligament. Above and external to it lie the arched fibres 
of the transversalis, below internally the deep epigastric artery. 
From its circumference a thin funnel-shaped membrane, the in- 
fundibuliform fascia, is continued around the cord 

Describe the external abdominal ring. 

The external abdominal ring is a triangular aperture in the 
fascia of the external oblique muscle, bounded below by the 
crest of the pubis, above by the intercolumnar fibres. Internally 
and above by the internal column inserted upon the front of the 
pubic symphysis. Externally and below by the external column, 
inserted upon the pubic spine. 

Describe Poupart's ligament. 

Poupart's ligament is that portion of the fascia of the external 
oblique muscle extending from the anterior superior spinous pro- 
cess of the ilium to the pubic spine. In the lower portion it 
forms the external column of the external ring ; a backward re- 
flection from the pubic spine to the pectineal line forms Gimber- 
naVs ligament. A band of tendinous fibres continued from its 
attachment to the pectineal line up and in towards the linea alba 
forms the triangular ligament. 

What is the cremasteric fascia ? 

It consists of the muscular fibres carried down from the in- 
ternal oblique by the testicle in its descent ; they form a series 
of loops covering the cord. 

What are the coverings of an oblique inguinal hernia? 

Skin, two layers of superficial fascia, intercolumnar fascia 
(from columns of external ring), cremasteric fascia (from canal), 
infundibuliform fascia (from internal ring), peritoneum (true 
sac). 

Name the coverings of a direct inguinal hernia. 

Skin, superficial fascia, intercolumnar fascia, conjoined ten- 
don, transversalis fascia, and peritoneum. 

If the hernia passes to the outer side of the conjoined tendon, 
this structure is replaced as a covering by the cremasteric fascia. 



HERNIA. 191 

What effect has a long-standing inguinal hernia upon the 
length of the canal ? 

The internal ring is dragged down till it lies almost directly 
behind the external ring. 

What is the relation of the cord to inguinal hernia ? 

Below and behind. 

In what direction should the incision be made in relieving the 
stricture of an inguinal hernia ? 

Upward and outward, parallel to Poupart ? s ligament. 

Describe congenital hernia. 

The testis, in its descent into the scrotum, is accompanied by a 
peritoneal pouch. The pouch becomes occluded at two points, 
the internal ring, and the top of the epididymis. The portion 
between these two points occupies the whole of the inguinal 
canal ; it shortly shrinks, and is transformed to a fibrous cord. 

If the peritoneal process remains patent throughout, we have 
the condition which gives rise to congenital hernia. 

If it is occluded at the lower end, hernia of the funicular pro- 
cess {infantile hernia). 

If it is occluded at the upper end only, and the occluding sep- 
tum yields, we have infantile hernia. 

How do you diagnose these forms of hernia? 

Congenital and funicular hernia (infantile) usually occur in early 
life, are of sudden development, become complete at once, do not 
drag down the internal ring. They are very prone to become 
strangulated, and are difficult to reduce. 

The congenital hernia intimately surrounds the testicle ; all 
other forms of hernia lie above it. 

The encysted hernia cannot be diagnosed before cutting ; then 
it will be found to have a double sac. 

Congenital hernia may be associated with undescended tes- 
ticle. In this case it will protrude outward along the fold of 
the groin. 

Prognosis of congenital hernia is good. 



192 ESSENTIALS OF SURGERY. 

With what affections may inguinal hernia be confounded? 

Varicocele, hydrocele of the cord, congenital hydrocele, and en- 
larged inguinal glands. 

How do you diagnose hernia from varicocele ? 

Varicocele feels soft, doughy, and like a bunch of worms to the 
fingers. Disappears on lying down, to appear again on stand- 
but first enlarges at the bottom of the scrotum. If it is made 
to disappear, and the finger is placed over the external ring, it 
will appear more quickly than before. No gurgling, no tympa- 
nites, slight succussion. An omental hernia may feel doughy, 
but not like a bunch of earth-worms, the enlargement comes 
from above, and if reduced, the finger placed over the external 
ring will prevent it from reappearing. 

How do you diagnose inguinal hernia from other affections of 
the same region ? 

Hydrocele of the cord is translucent, enlarges like varicocele 
from the bottom, and fluctuates. It has neither gurgling nor 
tympanites. 

Undescended testicle. Absence of gland on affected side, hard 
tumor in inguinal canal, sickening pain on pressure. 

Enlarged inguinal glands. Direction of tumor oblique to long 
axis of canal. It is hard, very painful, and the skin is reddened. 
Tumor freely movable at first. Hernia lies in the long axis of 
the inguinal canal, is soft, is not painful, the skin is normal, the 
tumor lies very deep, and is immovable. 



Femoral Hernia. 

Describe the femoral canal. 

The femoral or crural canal is a narrow interval below Pou- 
part's ligament, between the femoral vein and the crural sheath 
(sheath of the vessels). 

It is one-quarter to one-half inch long, extending from the 
femoral ring to the upper border of the saphenous opening. The 
septum crurale closes the canal at the femoral ring, the cribri- 
form fascia at the saphenous opening. 



HERNIA 



193 



Describe the femoral ring. 

The femoral ring lies between Poupart's ligament above, 
the pubis and pectineus muscle be- 



low, with Gimbernat's ligament to 



Fig. 48. 




Femoral hernia. 



the inner side, the femoral vein to 
the outer side. It is oval in shape, 
about one-half inch in diameter, and 
is closed by the septum crurale and 
a lymphatic gland. 

Describe the saphenous opening. 

The saphenous opening, formed 
by a reflection of the fascia lata 
beneath the femoral vein, is an oval- 
shaped aperture, one and one-half 
inches in length, one inch in breadth, 
situated beneath the inner portion of Poupart's ligament. 

Its upper and outer margin, sharply defined and semilunar in 
shape, passes in front of the vessels and is inserted into the 
pubic spine and pectineal line. It is called the superior comu 
of the falciform process. Its lower and inner margin forms the 
inferior comu of the falciform process. 

The inner margin is formed by the fascia passing to the pec- 
tineal line, curving upwards and behind the femoral vein, cover- 
ing in the pectineus muscle. This portion of the ring is not 
sharply defined. 

What are the boundaries of the femoral canal ? 

Anterior. Poupart's ligament, transversal is fascia, falciform 
process of fascia lata. 

Posterior. Iliac fascia, pubic portion of fascia lata. 

Internal. The junction of the transversalis and iliac fascia, 
forming the inner wall of the crural sheath, Gimbernat's liga- 
ment. 

External. The septum covering the femoral vein. 

What are the coverings of femoral hernia ? 

Skin, superficial fascia, cribriform fascia, crural sheath, septum 
crurale, peritoneum. 
13 



194 ESSENTIALS OF SURGERY. 

Where is the gut commonly strangulated in a femoral hernia? 

Gimbernat's ligament. Superior cornu of falciform process, 
or Hay's ligament. (Agnew.) 

What important structures lie near the femoral ring ? 

1. Spermatic cord, just above the superior margin. 

2. Epigastric artery, passes above to the outer side. 

3. Obturator artery, may curve across the upper and inner 
border. 

4. Femoral vein to the outer side. 

How do you distinguish femoral from inguinal hernia ? 

Femoral hernia, traced upward towards its neck, is found to 
pass to the outer side of the pubic spine. Inguinal hernia 
passes to the inner side. 

In what direction should you cut in relieving the constriction 
of a strangulated femoral hernia ? 

Upward and inward, using a blunt-pointed knife with a dull 
edge. 

How do you distinguish femoral hernia from a psoas abscess ? 

They both give succussion, and disappear on pressure or recum- 
bency. Psoas abscess comes down to the outer side of the vessels, 
gives the signs of the diseased condition by which it is caused, 
and fluctuates. It can be traced above PouparVs ligament. 
Hernia appears to the inner side of the femoral vessels and has 
the characteristic signs. It cannot be traced above Poupart's 
ligament. 

Umbilical Hernia. 

What are the varieties of umbilical hernia? 

1. Congenital, depends upon imperfect closure of the ventral 
plates, the sac extends into the cord and has been tied by the 
accoucheur. 

2. Acquired, depends upon yielding of the abdominal cicatrix. 
This is the commonest variety of umbilical hernia, both in infants 
and adults. 

What are the coverings of an umbilical hernia? 

Skin, superficial fascia, linea alba, sac. 



APPENDICITIS. 195 

How do you treat umbilical hernia ? 

In infants, draw the recti muscles together, strap tightly, and 
apply a binder or bandage. In adults apply a protecting con- 
cave truss. 

Where should the incision for relief of strangulated umbilical 
hernia be made ? 

In the linea alba, beginning a couple of inches above the upper 
margin of the hernia. The parietal tissues are often very thin. 



APPENDICITIS. 

What is appendicitis? 

An inflammation of the vermiform appendix of the caecum. 

What are the causes of appendicitis ? 

The disease is rare in infants, rare in the aged, and most com- 
mon in the young and the middle aged. The actual cause of 
the disease is bacterial infection. The usual microbic cause is 
the bacterium coli commune ; but pus cocci alone or in con- 
junction with colon bacilli may be the causative agents. These 
organisms do no harm to a healthy appendix, but attack with 
violence a damaged one, because when the appendix is dam- 
aged by disease or injury it becomes a point of least resistance. 
The appendix may be damaged by being bruised, by being 
kinked or twisted, by the action of catarrhal inflammation of 
its* mucous lining, or by the presence of a foreign body or a 
stercoral concretion. In most cases the appendicular outlet is 
sealed and the appendix is converted into a closed cavity. 
Genuine foreign bodies are rarely found. Stercoral concretions, 
frequently resembling grape-seeds, are often found. 

Name some of the possible results of appendicitis. 

Peritonitis, perforation, gangrene of the appendix, and ab- 
scess-formation. 

Name the chief forms of appendicitis. 

Catarrhal, suppurative, perforative, gangrenous, obliterative, 
and chronic relapsing appendicitis. 



196 ESSENTIALS OP SURGERY. 

Give the symptoms of acute appendicitis. 

The patient usually feels unwell for a day or so. There may, 
however, be no premonitory symptoms, the condition arising 
with great suddenness. There develop loss of appetite, dys- 
pepsia, flatulence, colicky pain about the umbilicus, nausea, 
occasionally vomiting, and generally constipation, but possibly 
diarrhoea. Pain develops in the right iliac fossa, and examina- 
tion discloses acute tenderness, fulness, and marked muscular 
rigidity. The point of most acute tenderness is known as 
" McBurney's point." In many cases this is found two inches 
internal to the anterior superior iliac spine, on a line from the 
iliac spine to the umbilicus. The pulse is about 100 or over. 

Is there fever? 

As a rule, there is moderate fever, but in some of the worst 
gangrenous cases the temperature may be normal or even sub- 
normal. When pus. is forming the temperature is usually irreg- 
ular, and the periods of fall are accompanied by sweating. 

What course may the symptoms take? 

The symptoms may disappear and the patient recover ; they 
may suddenly become aggravated, because of gangrene or per- 
forative peritonitis ; or they may gradually become worse. In 
this case the pain becomes violent and the tenderness acute. 
The patient lies on his back with the right leg drawn up. 
Rectal or vaginal examination may disclose tenderness or the 
existence of an inflammatory mass. 

What prognostic significance has the pulse? 

A very rapid pulse gives a bad prognosis. A pulse much 
above 100 is a bad sign. 

What is the result of a sudden perforation ? 

Collapse, followed by rapidly fatal general peritonitis. 

What is the result of a gradual perforation? 

Pus forms outside of the appendix, and is often limited by 
adhesions (appendicular abscess). 

Can the inflamed appendix be palpated? 

In many cases an enlarged appendix can be palpated if the 
abdomen is thin and not rigid. It may be palpated in an inter- 



APPENDICITIS. 197 

val between attacks. It is not wise to palpate forcibly in acute 
appendicitis, as the diseased structure may be ruptured. 

What are the terminations of appendicitis? 

Recovery. Death. A condition of impaired health, further 
attacks being sure to occur. 

What is the treatment of appendicitis ? 

Appendicitis is a surgical disease. Some surgeons operate on 
every case as soon as the diagnosis is made. Many surgeons 
operate when the symptoms are severe, but in a case with ordi- 
narily mild symptoms they put the patient to bed, apply an 
ice-bag over the right iliac fossa, and administer a saline purge. 
McBurney's rule is as follows : If the patient is no worse six 
hours after the attack begins, wait longer. If the symptoms are 
no worse in six hours more, they will probably soon improve. 
If in twenty-four hours after the beginning of an attack the 
symptoms have improved, the surgeon can usually postpone 
operation until an interval. If during the second twenty-four 
hours the symptoms have grown worse or have not continued 
to improve, operate at once. 

After a single attack has passed away should the appendix 
be removed? - 

If there is tenderness or pain, yes. If the patient has no dis- 
comfort or tenderness, operation is not demanded, as there may 
never be a second attack. 

After two or more attacks should the appendix be removed? 

Yes; because after two attacks others will almost certainly 
arise. 

When should the interval operation be performed? 

About three weeks or more after the attack. 

Should the appendix be removed in every operation for acute 
appendicitis ? 

No. It should be removed in most cases. It should be re- 
moved in some abscess cases. When it constitutes part of an 
abscess-wall, it should not be removed, because, if removal is 
effected, the abscess-wall will be broken down and pus will 
obtain access to the general peritoneal cavity. 



198 ESSENTIALS OF SURGERY 



INTESTINAL OBSTRUCTION. 

Give the causes of acute intestinal obstruction. 

1. Congenital malformation, imperforate anus, etc. 

2. Impaction of foreign bodies and gall-stones. 

3. Invagination or intussusception. 

4. Volvulus or twisting, commonly dependent on mesenteric 
elongated. 

5. Internal strangulation, or constriction of the bowel by 
bands or diverticula having no structural connection with the 
circumference of the constricted gut. 

Symptoms of acute intestinal obstruction may also appear in 
enteritis, peritonitis, and perityphlitis; or in chronic obstruction. 

Give the symptoms of acute intestinal obstruction. 

Pain, often intense and localized. Vomiting, gastric, bilious, 
intestinal, and finally fsecal. Constipation, absolute. Abdomen 
swollen, tender, tympanitic. Peristalsis increased, causing borbo- 
rygmus and gurgling. Great vital depression. Small, rapid pulse. 
Temperature may be normal or subnormal till just before death, 
which commonly occurs in from seven to ten days. 

How may the seat of acute intestinal obstruction be inferred ? 

The probability of the stnall intestine being involved is in 
direct proportion to the acuteness of the pain and the rapidity 
of the course. Early and severe vomiting, scanty urine, and 
early distension all point to small intestine. 

What are the causes of chronic obstruction ? 

Fsecal accumulation, stricture of the bowel, glueing of the in- 
testines together from chronic peritonitis or cancer, abdominal 
tumors. 

Give the symptoms of chronic obstruction. 

Constipation ; abnormal distension very slowly developed ; vom- 
iting comes on slowly or may be absent ; pain rarely acute ; con- 
stitutional depression not marked. 



INTESTINAL OBSTRUCTION. 199 

What are the special characteristics of intussusception ? 

This is the common form of acute obstruction in infancy and 
childhood. Usual seat, ilio-colie valve. It is characterized by 
tenesmus and passage of mucus and blood. 

Sausage-shaped tumor usually to the left side of the abdomen. 

On examination per rectum the invaginated gut may be 
found. 

Give the treatment for intussusception. 

Inflation per rectum with air or water ; inversion ; gentle 
kneading of the bowels. 

Laparotomy, and reduction by kneading and drawing down the 
sheath or outer tube. If reduction is not possible, make an arti- 
ficial anus, or cut off the intussuscepted part, and suture together 
the two ends of the bowel. 

What are the special characteristics of internal strangulation? 

Occurs during adolescence or early adult life. 

Patient has been previously healthy, symptoms following a 
blow or a straining effort. 

Symptoms very acute. Severe pain referred to umbilicus with 
intense prostration or syncope. There is no peristalsis, no tumor. 

What are the special characteristics of volvulus ? 

Occurs in advanced life. 

Seats. Sigmoid flexure of colon, and in the neighborhood of 
the ilio-csecal valve. 
Symptoms are characterized by extreme rapidity and severity. 

Give the treatment of acute intestinal obstruction. 

Make most carefid search in all hernial regions for strangidation. 
Keep the patient in the recumbent position. Give liquid nour- 
ishment and in minimum quantity. Morphia gr. \ every three 
to six hours, as required to relieve pain. Hot fomentations to 
the belly. Cocaine, hydrocyanic acid, etc., for vomiting. If, 
after a reasonable time (one to three days, according to the se- 
verity of the symptoms), there is no change for the better, 
laparotomy, with further measures adapted to the relief of the 
obstruction. 



200 ESSENTIALS OF SURGERY. 

Give the treatment of chronic intestinal obstruction. 

Enemata. If from impaction of feces, break up mechanically 
and remove. If from malignant trouble, or stricture, excision, 
with circular enterorraphy or artificial anus. 

What is laparotomy? 

Opening the abdominal cavity. 

Incision. Linea alba, midway between pubes and umbilicus, 
large enough to admit the fingers. Stop all bleeding before open- 
ing peritoneum. Explore first all the hernial rings, then the 
ccecam. If it be distended, obstruction must be in large intestine, 
and can be found by searching along the colon. If caecum empty, 
search for an empty loop of small intestine, which can be fol- 
lowed up till the seat of trouble is reached. 

If intestine sloughing, enterectomy (excision), and artificial anus 
or circular enterorraphy (suture). 



Diseases of the Anus and Rectum. 

Describe the varieties of congenital malformation of the anus 
and rectum. 

1. Partial or complete occlusion of the anus. There is a mem- 
brane of varying thickness, bulging when the child cries or 
strains, and thin enough for the meconium to be detected. 

2. Imperforate anus. The rectum terminates in a blind pouch, 
from half an inch to an inch from the surface ; the normal posi- 
tion of the anus is occupied by dense tissue. 

3. Occlusion of the rectum. A membranous septum is found 
from half an inch to an inch above the anal orifice. 

4. Imperforate rectum. Rectum wanting. The colon termi- 
nates in a blind pouch in the iliac fossa. 

5. Malformation with abnormal opening in other parts. 

How do you treat congenital malformation of the anus and 
rectum ? 

Place the child in lithotomy position. 

Incision in the middle line, over the natural position for the 
anus. Work backward toward the coccyx. The bowel being 



DISEASES OF THE ANUS AND RECTUM. 201 

found, open, and, if possible, suture to the external wound. Pass 
a bougie daily to prevent contraction. If, after dissecting to the 
depth of H inches, no sign of bowel is perceived, do Littre's 
operation (left inguinal colostomy), making an artificial anus. 
Recently, osteoplastic resection of the sacrum has been advised 
as a plan which will disclose the rectum. 

What are hemorrhoids ? 

Swellings about the margins of the anus due to a varicose 
condition of the bloodvessels. Hemorrhoids may be external, 
affecting the muco-cutaneous folds external to the sphincter, or 
internal, affecting the mucous membrane within the sphincter. 

What are the causes of hemorrhoids ? 

Anything tending to increase the. supply of blood to the rectum, 
or to impede its venous return. Instance, liver troubles, constipa- 
tion, straining, occupations requiring much standing, sedentary 
life. They begin as dilations of the hemorrhoidal veins, and are 
followed by infiltration of surrounding tissues. 

Describe external piles. 

May be made up of dilated and thrombosed veins, thrombotic; 
may be due to swollen muco-cutaneous folds, oedematous ; or may 
consist of permanently hypertrophied flaps or tags of skin, 
cutaneous. These occasion little trouble till, from cold, consti- 
pation, imprudent diet, or some other cause, they become in- 
flamed, when they give rise to intolerable pain and itching, and 
exhibit all the local signs of an acute inflammation ; this con- 
stitutes an "attack of piles." 

Give the treatment of external piles. 

Keep the bowels open by equal parts confection of senna and 
confection of black pepper, or a glass of Friedricb shall on rising 
in the morning ; scrupulous cleanliness of the parts. Cocaine 
suppository (gr. \) for acute attacks. 

Thrombotic. Apply a ten grain to the ounce calomel ointment 
at night and in the morning, after washing. If the parts become 
very painful, incise and turn out the clot. 

Describe internal piles. 

May be open or bleeding, blind or not bleeding. 



202 ESSENTIALS OP SURGERY. 

1. Capillary hemorrhoids. Small, granular, bright red tumors, 
situated high in the bowel ; really arterial nsevi. 

2. Arterial hemorrhoids. Hard, vascular, glistening, slippery ; 
may attain considerable dimensions. On scratching, bright red 
blood in jets. Large artery can be felt entering the upper part 
of each pile. 

3. Venous hemorrhoids. Large, livid, prone to prolapse. 

What are the symptoms of internal hemorrhoids ? 

Bleeding at stools. The blood is bright red and coats the fceces. 
Protrusion. An irregularly nodulated congested mass protrudes 
after defecation. It may become strangulated by the sphincter. 
Constipati07i. Discomfort and heaviness about the rectum. Pain 
and fever, if the piles are inflamed or strangulated. 

Give the treatment for internal piles. 

1. Palliative. Equal parts of senna and black pepper confec- 
tion, a teaspoonful on rising. Coat the diseased area with ferri 
subsulph. 3ss, cosmoline §j. Inflamed piles. Laudanum and 
starch-water injections. Hot fomentations. Cocaine supposi- 
tories (gr. i). For strangulated piles, anaesthetize, and return 
within the sphincter. 

2. Operative. Clear the lower bowel by laxatives and injection. 
Lithotomy, or the lateral position. (1) Injection of carbolic acid. 
Clamp the pile and inject TTLv of a 20 per cent, glycerine and 
water carbolic solution into the centre of the pile. (2) Ligature. 
Paralyze the sphincter, draw down each pile, divide the skin 
about it, and encircle its base by a ligature ; or transfix with a 
needle carrying a double thread, and tie each half separately. 
Insert an opium suppository and apply a T bandage with a 
compress of iodoform gauze. Open the bowel on the fifth day. 

3. Clamp and cautery. 4. Crushing. 

5. Excision of pile-bearing area by Whitehead's method. 

Give the treatment for secondary hemorrhage after pile opera- 
tions. 

Cold injections. Pass in a full-sized drainage-tube and pack 
the rectum about it with styptic cotton or gauze (containing 
subsulphate of iron). Separate sphincter, find bleeding point, 
and ligate. 



DISEASES OF THE ANUS AND RECTUM. 203 

Name the forms of prolapse of the rectum. 

Partial, involving only mucous membrane. 
Complete, involving all the tissues of the gut (really an invagi- 
nation). 

Name some of the causes of prolapse. 

Relaxation. Undue straining. Irritation, such as that caused 
by ascarides, polypus, stone in bladder, phimosis. 
Usually occurs in children or aged people. 

Give the symptoms of prolapse. 

A protrusion of a soft, non-nodulated, non-pediculated, smooth 
mass about the entire circumference of the anus, continuous 
with the mucous coating of the sphincter in the partial form. 

Give the treatment of prolapse. 

Eeduce. Patient in knee-breast posture ; bowel covered with 
oiled lint and pushed up. If strangulated, divide the sphincter. 
After reduction strap the nates together (plaster), keep bowels 
soluble, and let them be moved while the patient is in the 
recumbent or standing posture. The cold douche, or astringent 
injections are often serviceable. 

Operative. 1. Take up longitudinal folds of mucous membrane 
in Smith's clamp, cut off with scissors, and cauterize pedicle 
(clamp and cautery). 2. Ligate portions of the mucous mem- 
brane. 3. Apply nitric acid to entire prolapsed surface, cover 
with carbolized oiled lint, and restore. 

What is a fistula in ano ? 

An abnormal communication between the rectum and the 
surface. 

Usual cause. Abscess. 

Name the varieties of fistula in ano. 

Complete, having a gut and a surface opening. The gut open- 
ing is usually just above the internal sphincter. 
Incomplete or blind, having but one opening. 

a. External, opens on surface only. 

b. Internal, opens in bowel only, 



204 ESSENTIALS OF SURGERY. 

What are the symptoms of fistula in ano ? 

1. Discharge. Thin pus, causing excoriations, and coating the 
fasces in the internal or blind variety. 

2. Local signs of inflammation, which are subject to frequent 
exacerbations. 

3. Opening, sometimes very small. On using a probe its end 
will be felt by the finger in the rectum, either passing into the 
bowel, or, if there be no internal opening, lying beneath the mu- 
cous membrane. 

Give the treatment for fistula. 

Operation. Pass a grooved director along the fistulous tract 
till its point is felt on the finger introduced into the bowel, hook 
it forward bringing it out through the anus, divide the structures 
thus raised upon the director and all sinuses or pockets communi- 
cating with the fistula. Do not divide the sphincter in more 
than one place. In women do not divide the sphincter, as it 
decussates with the vaginal fibres. Wipe out the wound with 
caustic potash, pack with lint saturated in carbolized oil, and 
allow the wound to heal from the bottom. In some cases it is 
well to dissect out the fistula, sew up with buried sutures, and 
try to obtain primary union. 

What is anal fissure? 

Anal fissure is a lineal ulcer or crack, usually just within the 
anus. Caused by constipation, and large hard passages. 

Give the symptoms of anal fissure. 

1. Smarting pain coming on after defecation, often intense and 
radiating from rectum. Smarting changed to an aching sensation , 
which may last for several hours. 

2. Faeces streaked with blood. 

How do you diagnose anal fissure ? 

Examination is painful; the sphincter and levator ani are 
spasmodically contracted. Two cedematous folds of mucous 
membrane are found, which being separated reveal the ulcer. 

Give the treatment of anal fissure. 

1. Keep the bowels loose (cascara sagrada gr. iij. at night, or 



DISEASES OF THE ANUS AND RECTUM. 205 

Hunyadi Janos on rising), wash with soap and warm water after 
each passage, and apply ferri subsulph. (gr. x to ^j cosmoline). 

2. Anaesthetize the patient. Insert the thumbs into the anus, 
separate them till the ischial tuberosities are felt. 

3. Local anaesthesia by cocaine (gr. xx to gj). Draw a bis- 
toury longitudinally through the base of the ulcer from above 
downwards. 

What other forms of ulceration occur about the anus and 
rectum ? 

Syphilitic, tubercular, senile (varicose). 

Give the symptoms of ulcer of the rectum. 

Tendency to morning diarrhoea. There is an urgent desire to 
open the bowels immediately on rising. 

Pain, moderate. Tenesmus, relieved by evacuation. 

Discharge. Mucus or muco-pus, at times containing also 
disintegrated blood. 

Ulcerated surface is seen a,ndfelt on examination. 

Give the treatment of ulceration of the anus and rectum. 

Treat constitutional condition. Highly nutritious diet, bowels 
soluble. Night and morning, cleansing injections of warm bor- 
acic acid solution (ad lib.), or boroglyceride ; at night starch 
water and laudanum gttxx by injection. In severer cases 
nitric acid directly to ulcer, applied through speculum. 

Name the varieties of stricture of the rectum. 
1. Fibrous. 2. Malignant. 

What is the cause of simple (fibrous stricture) ? 
Inflammation or ulceration. 

What are the symptoms of fibrous stricture ? 

1. Constipation, slowly increasing. 

2. Motions like pipe-stems, or broken up into scybala. 

3. A sense of fullness after passages, as though there were more 
to come. 

4. Diarrhoea, alternating with constipation, or predominating. 
Constant desire to go to the closet, passage of very little solid, 
with yeasty liquid. 



206 ESSENTIALS OF SURGERY. 

5. Wind which cannot be passed except in the closet, as it is 
accompanied by a liquid discharge. 

6. Excoriation and inflammation of anus from discharge. 
Frequently fistula. 

By examination the stricture can usually be felt. 

Give the treatment for fibrous stricture of the rectum. 

Gradual dilatation by means of bougies. Partial or complete 
division of the stricture. Inguinal colotomy. Excision of stric- 
ture. 

Give symptoms and treatment of malignant stricture of the 
rectum. 

Usually epithelioma ; about half inch above anus. In addi- 
tion to the signs of stricture, there is intense pain radiating from 
the seat of trouble, there is frequently free bleeding, and the 
discharge is profuse, offensive, watery, or often bloody, and 
becomes finally like coffee-grounds. Cancerous cachexia always 
develops. On examination, the abnormal growth is detected ; 
indurated, nodulated, and, if the disease is advanced, with 
fungoid out-croppings over its surface, which break down under 
the examining finger, coating it with a blood-stained offensive 
muco-pus. 

Treatment. Excision if the disease is strictly local, inguinal co- 
lostomy if it is irremovable or if there is systemic involvement. 

Give the symptoms of impacted faeces. 

Constipation, distension, pain, and very frequently a spurious 
diarrhoea, i. e., a mucous semi-fseculent discharge, due to the 
irritation of the impacted mass. 

Diagnosis by rectal examination. 

Treatment. Break up the lower part of the mass with the 
finger or the handle of a wooden spoon, and wash away by 
means of copious injections. 

Describe polyp of the rectum. 

Two varieties. 1. Fibrous. Smooth surface, may reach large 
size. 2. Adenoid. Identical in structure with the mucous mem- 
brane ; looks very much like a raspberry. Both usually pedun- 
culated : occur in children. 



DISEASES OF THE ANUS AND RECTUM. 207 

Symptoms. Bleeding after stools, and prolapse. 
Treatment. Ligate and remove. 

Describe villous tumors of the rectum. 

Practically a mass of non-pediculated adenoid polyps. 
Symptoms. Hemorrhages, feeling of fulness in rectum, and 
thin, mucoid, glutinous discharge. 
On examination a lobulated, soft, velvety, movable mass is found. 
Treatment. Complete removal. 

Describe pruritus ani. 

Obstinate itching about the anus ; frequently depending on 
local irritation (as pediculi, threadworms, piles), or on gouty 
diathesis ; it may be without obvious cause. 

Give treatment of pruritus ani. 

Kemoval of cause, strict cleanliness, regularity in the motions 
from the bowels, exercise, Turkish baths. Suppositories of 
cocaine (gr. i) or iodoform (gr. v), morphine, carbolic acid, 
mercurial ointment. Alum and zinc sulphate, equal parts of 
each, fuse, powder, dissolve in 3j aq. ; use as injection. A rec- 
tal plug may be worn at night. 






208 ESSENTIALS OF SURGERY. 



VENEREAL DISEASES. 

What is syphilis? 

Syphilis is a contagious constitutional disease due to inocu- 
lation with specific virus. 

What is the primary lesion of syphilis? 
The chancre. 

What is the period of primary incubation? 

The time which intervenes between inoculation and the ap- 
pearance of chancre. Rarely earlier than two weeks or later 
than five ; average, three weeks. 

What is the period of secondary incubation ? 

The time between the appearance of chancre and the develop- 
ment of secondary symptoms. Rarely before the first or after the 
third month succeeding the chancre. 

When do the tertiary symptoms appear ? 

At a period varying from a few months to many years after 
the secondaries. 

Describe chancre or primary sore. 

Found commonly about the corona glandis, may appear any- 
where. Contracted directly, by contact with chancre or second- 
aries (mucous patches), indirectly from articles used by syphilitics. 

Appears as an indurated papule, which develops into an 
abrasion, tubercle, or ulcer. 

What are the characteristics of the primary sore? 

1. Indurated base and thin, scanty secretions. 

2. Inflammation slight around the sore. 

3. Usually single, not autoinoculable. 

4. Buboes are poly ganglionic and painless ; rarely suppurate. 

5. Appears after an incubation period and is followed by sec- 
ondaries. 

The Hunterian chancre is characterized by greater depth, freer 
discharge, and more marked induration. 



VENEREAL DISEASES. 209 

The mixed chancre exhibits the peculiarities of both syphilitic 
and chancroidal inflammation. 

Give the treatment of chancre. 

Wash several times daily with black wash, and dust with 
calomel, subiodide of bismuth, iodol, or iodoform. Do not begin 
mercury till the secondaries appear. 

Describe the secondary lesions of syphilis. 

1. General enlargement of the lymphatic glands. 

2. Eruptions of the skin and mucous membranes ; at times, in- 
flammation of the iris or periosteum, and falling of the hair. 

Pathology. Congestion, infiltration, ulceration. 

The development of secondaries is preceded by general malaise, 
fever, and anaemia, lasting a few days and disappearing on the 
appearance of roseola and sore throat, ^r 

The skin eruption may simulate the various forms of skin dis- 
ease. It may be erythematous (s. roseola), papular (s. lichen), 
vesicular (s. herpes, eczema, and varicella), bullous (s. pemphigus), 
or pustular (s. ecthyma, acne, or variola). 

Mucous membrane lesions. 

Pathology, as in the skin, first congestion (syphilitic sore 
throat), then infiltration with maceration of the epithelium 
(mucous patches), finally ulcers. 

What are the characteristics of syphilitic skin eruptions ? • 

1. Absence of itching. 

2. Symmetrical arrangement (on the two sides of the body). 

3. Reddish-brown or coppery in color (raw ham). 

4. Polymorphous (many kinds of eruption at the same time). 

5. Therapeutic test (use of mercury). 

Describe the mucous patch. 

Synonyms. Condyloma. Mucous tubercle. 

Pathology. A congested, infiltrated macule, the surface of 
which is, from its peculiar position (about the anus, on the 
scrotum, in the gluteal folds), continually moist, in consequence 
of which the epithelium becomes sodden. 

Appearance. A somewhat elevated, flat macule, covered with 
a dirty whitish, offensive exudation. 
14 



210 ESSENTIALS OF SURGERY. 

Give the treatment of secondary syphilis. 

Mercury ; liydrarg. prot. iodid. gr. % three times daily, guard- 
ing the bowels by opium. Increase the dose gradually till the 
patient exhibits the offensive breath or the beginning mouth 
tenderness of ptyalism. Then cut the daily quantity down one- 
half, and continue for eighteen months, unless new symptoms 
appear, when the dose may be temporarily increased. After 
eighteen months, add iodide of potassium, and continue for six 
months or a year. 

Mercury may be given : 1. By the stomach. 2. By inunction. 
3. By vaporization. 4. By hypodermatic injection. 

By inunction. Unguent, hydrarg. jss to £j at night ; rubbed 
into the feet after they have been soaked in hot water. The 
same stockings must be worn night and day. 

Mucous patches should be washed with black wash, and dusted 
with a powder made up of calomel one part, zinc-oxide two 
parts. 

Sore throat is treated by astringent gargles. 

Describe the tertiary lesions of syphilis. 

Between the secondaries and tertiaries proper there are certain 
symptoms, called reminders, which sometimes appear. Among 
them are skin eruptions, enlargement of the testicle, choroiditis, 
ulceration of the tongue, disease of the arteries, and psoriasis of 
the palms. 

Tertiary lesion of syphilis is the gumma. This has no tendency 
to spontaneous cure, and is characterized by the formation of 
masses of granulation cells, which commonly infiltrate the sur- 
rounding tissues, and break down in the centre. 

A gumma may break down, leaving an ulcer, or may be ab- 
sorbed, leaving fibroid thickening and scarring (syphilitic stricture 
of rectum and oesophagus, etc.). The gumma may attack the 
periosteum, causing nodes, caries, or necrosis ; the cutaneous 
and mucous surface, causing ulcers on any part of the body. 

These ulcers of tertiary syphilis are asymmetrical, and are not 
contagious. 



.«-.*»■ 



VENEREAL DISEASES. 211 

Give the treatment of tertiary syphilis. 

Mercury and potassium iodide, or iodide of potassium alone or 
combined with tonics. Commence with ten grains of potassium 
iodide three times a day, gradually increasing the dose till the 
desired effect is accomplished. 

What are the characteristics of a tertiary ulcer? 

Begins as a gumma or lump, which, when it breaks, exposes a 
gray slough, surrounded by granular tissues. The edges are 
rounded and sharply cut. Other signs of syphilis can be found. 
The affection yields to specific treatment. 

Syphilitic leg ulcers usually involve the upper third. 

What is congenital syphilis? 

Syphilis transmitted to the foetus through the spermatozoa of 
the father, or the ovum of the mother. 

What are the characteristics of congenital syphilis ? 

Manifestations are rare before four to six weeks after birth ; 
then there may be secondaries, as snuffles or coryza, macular or 
papular eruptions, mucous patches, ulcerations about the mouth 
and lips (rhagades), stomatitis, which, by its effect upon the 
dental sacs of the permanent teeth, causes the subsequent de- 
velopment of Hutchinson's teeth. After some years, tertiaries 
develop. These commonly take the form of interstitial keratitis, 
and gummatous developments. 

Describe Hutchinson's teeth. 

The upper permanent median incisors chiefly show this lesion, 
which consists in a dwarfing of the entire tooth, an extreme 
diminution in its free end, and a narrowing of the cutting edge, 
with a central notch or crescent. 

Give the treatment of hereditary syphilis. 

Upon the same lines as the acquired secondaries. Mercury best 
given by inunction, gr. x. unguent, hydrarg. being rubbed over 
the abdomen and covered by the belly-band every night. Stop 
mercury shortly after disappearance of symptoms. Prevent a 
non-infected woman from suckling the child. 

Tertiaries, Mercury and iodide with tonics. 



212 



ESSENTIALS OF SURGERY. 



What is Colles's law? 

A syphilitic child suckled by its mother will not infect her, 
though she be (apparently) free from venereal disease. 

Chancroid. 

What is a chancroid ? 

Chancroid is a local contagious ulceration caused by contact 
with the secretions of a similar ulcer. 

What are the characteristics of chancroids ? 

1. No period of incubation. Appears in from three to five 
days ; first as a papule, then a vesicle or pustule, very shortly 
an ulcer. 

2. Usually multiple. 

3. Inflammatory in type, with punched-out edges, irregular 
sloughing surface, and abundant discharge. 

4. Monoganglionic and unilateral lymphatic involvement. 
May be simple inflammatory enlargement, or virulent bubo from 
direct absorption and suppuration. 

5. Autoinoculable. 

6. Not indurated. 

7. Not followed by secondaries. 

How may a chancroid be complicated ? 

Phagedenic ulceration. Characterized by very rapid and exten- 
sive sloughing. 

Serpiginous ulceration. Characterized by slow but persistent 
extension. 

Phimosis. Paraphimosis. 

Give the treatment for chancroids. 

1. Cauterize with hot iron, sulphuric or nitric acid. Dress 
with black wash or iodoform. 

2. Cleanse thoroughly with acid, nitric, £ss, aq. foviij. Dust 
with iodoform, or zinc oxide one part, bismuth two parts. 

Bubo. Try to abort by blisters, iodine around the inflamed 
area, or pressure by means of a salt or shot-bag. If it sup- 
purates, open. If it is a simple inflammatory bubo, it quickly 



VENEREAL DISEASES. 213 

heals ; if it is chancroidal, it has no tendency to heal, but must 
be thoroughly cauterized. After operation pack with iodoform 
gauze and dress antiseptically. 

Phagadenic ulceration. Remove slough and thoroughly cauterize. 
Continuous warm bath is frequently curative. Internally, tonics, 
opium and iron, rich food, and alcoholic stimulants. 

Serpiginous ulceration. Repeated applications of the actual 
cautery to the entire diseased surface, together with nourishing 
and stimulating internal treatment. 

What is primary bubo or bubon d'emblee ? 

A simple adenitis resulting from mechanical irritation. It is 
seen at times, after coitus, when there is no taint of chancroid, 
gonorrhoea, or syphilis. 

Gonorrhoea. 

Describe the urethra. 

Length, 8 to 9 inches. 

Three portions. Spongy, membranous, and prostatic. 

Spongy portion. 6 inches long from meatus to anterior layer 
of triangular ligament. Meatus narrowest portion of urethra. 
Lacuna magna, a large mucous follicle 1^ inches from meatus on 
the upper surface of urethra ; its opening is directed forward 
and may catch instruments. Glandular and bulbous parts of the 
spongy urethra somewhat dilated. 

Membranous portion, § inch long. From apex of prostate to 
beginning of spongy portion, between the two layers of the tri- 
angular ligament, 1 inch below pubic arch. Except meatus, the 
narrowest part. Embraced by compressor urethrse muscle. 

Prostatic portion. \\ inches long. Widest and most dilatable 
part; passes through prostate near its upper surface. 

What is gonorrhoea ? 

Gonorrhoea or clapis a contagious (probably specific) inflamma- 
tion attacking mucous membranes, particularly those of the 
genito-urinary tract. 

Cause. Direct contagion (gonococcus). Urethritis, identical 
with gonorrhoea, is developed by contact with retained and foul 



214 ESSENTIALS OF SURGERY. 

discharges (leucorrhoea), or other irritants. It begins in the 
male usually in the fossa navicularis, and passes backward. In 
the female it begins in the vulva and vagina. 

Name the clinical varieties of gonorrhoea. 

1. Acute inflammatory (typical). 2. Subacute or catarrhal. 
3. Irritative or abortive. 

What are the stages of an acute attack ? 

First, or increasing stage. Second, or stationary stage. Third, 
or subsiding stage. 

What are the first symptoms of gonorrhoea ? 

Usually, in three to five days, there is a tickling sensation at 
the meatus, which is changed to a burning at the next urina- 
tion. On examination, the lips of the meatus are somewhat 
reddened and everted, and there is a slight muco-purulent dis- 
charge. In a very short time (twelve to twenty-four hours) the 
patient reaches the well-developed first stage. 

Give the symptoms of the increasing stage, 

1. Ardor urinse. 2. Profuse purulent discharge. 3. Chordee 
(painful erections). 4. Frequent urination. 

What are the complications of the first stage ? 

1. Balanitis, or inflammation extending over the glans penis. 

2. Balano-posthitis. Inflammation of the mucous layer of the 
foreskin. 

3. Phimosis, or inability to retract the foreskin, from oedema- 
tous swelling. 

4. Paraphimosis. The retracted and swollen foreskin cannot 
be brought forward. 

The first stage lasts about one week. 

Give the symptoms and complications of the second stage. 

The inflammation gradually extends backward. There is a 
continuance of the symptoms of the first stage, with possibility 
of the following complications : — 

Follicular abscesses, appearing as small, round, tender tumors 
along the floor of the urethra. They may open either internally 
or externally. 



VENEREAL DISEASES. 215 

Periurethral abscess. Favorite seat about the fossa navicularis 
and the anterior membranous portion of the urethra, where the 
disease is most persistent. 

Lymphangitis. Dependent usually on retention of discharge 
beneath prepuce. Thick, tender, reddened cord-like line along 
dorsum of penis. 

Bubo. One gland affected ; may undergo resolution, or may 
suppurate. 

Cowperitis. Characterized by very intense throbbing pain. 
Painful urination, especially at the end of the act (compressor 
urethra? m.), and the detection of the hard, inflamed glands by 
examination of the perineum. 

Second stage lasts one or two weeks. 

Give the symptoms and complications of the stage of subsidence. 

Symptoms as of the other stages. They may be complicated 
by epididymitis, characterized by pain of an intense and sicken- 
ing character passing along the cord to the loins, swellings, out- 
lined at the back of the scrotum and considerable in extent, and 
tenderness ; there is nearly always fever. 

Describe subacute or catarrhal gonorrhoea. 

Occurs usually in persons who have had previous attacks. Is 
characterized by very free discharge, with absence of other symp- 
toms or complications. Yields rapidly to treatment, but does 
not entirely disappear, a drop or two of muco-pus being dis- 
charged daily. 

What are the complications of subacute gonorrhoea? 

Qonorrhceal rheumatism or urethral synovitis. Characterized by 
slight constitutional symptoms and a rapid development of syno- 
vitis in knee, ankle, wrist, or elbow. 

Gonorrhoeal ophthalmia (sclerotitis, iritis), or conjunctivitis. 

Describe irritative or abortive gonorrhoea. 

The symptoms are those of beginning acute gonorrhoea, i. e., 
redness, pouting, and tingling or itching at the meatus, with a 
very slight mucous discharge. The disease does not advance be- 
yond this point. These symptoms may persist for several days, 
then disappear. No complications, no sequelae. 



216 ESSENTIALS OF SURGERY. 

Give the treatment of gonorrhoea. 

Rest in bed, if possible, on a diet of skimmed milk, giving plenty 
of bland liquids, such as Apollinaris water, soda water, etc. Keep 
the bowels open. To make the urine alkaline, and to act as a 
sedative, give — 

I£. Tr. aconit. rad. gtt. xvj. 

Pot. brom. 5iij. 

Infus. pareir. brav. fSviij. 
S. fgss in aq. every two hours. 

For ardor urince give the above prescription. Immerse the 
penis in hot water during urination. Wrap the organ in cloths 
saturated with — 

Tr. aconit. rad., 

Tr. opii, 

Alcohol, aa gj. 

Liq. plumb, subacetat. dil. fSiij. 

Cliordee. Bromide of potassium till drowsiness is produced ; 
a double dose on retiring, repeated during the night. 

If the patient wakes with chordee, camphor gr. iij, opium 
gr. j, as a suppository or hypodermics of morphia (gr. \) injected 
into the perineum. 

When the disease has reached its height and is declining , give 
capsules of cubebs and copaiba, TTLxx of each, every two hours. 

Injections may now be used — 

Bismuth, subnit. 5j. 
G-lycerin, f3ij. 
Aq. ros. q. s. fgiv. 

Followed in a few days by — 

Zinc, sulph. gr. viij. 
Morph. sulph. gr. j. 
Aq. ros. fgiv. 

Gradually stop injections and internal medication. 

What are the causes of chronic urethral discharge ? 

1. Urethral catarrh. 

2. Chronic gonorrhoea, a localization of the disease, producing 
a granular and somewhat ulcerated surface. 

3. Stricture of urethra. The usual cause of gleet. 



■M 



VENEREAL DISEASES. 217 

How can the nature of chronic urethral discharge be deter- 
mined ? 

Urethral catarrh immediately follows gonorrhoea, and presents 
no symptoms beyond a thin, watery discharge. 

CJironic gonorrhoea discharges creamy pus, is greatly aggravated 
by any excess. There is some burning at urination, and at times, 
chordee. It is generally found about the navicular fossa and the 
bulbo-membranous portion of the urethra. Examination by 
a bulbous bougie detects a rough, tender spot, and pus and blood 
may be brought away upon the shoulder of the instrument. 

Gleet from stricture appears some time after subsidence of 
gonorrhoea. It is characterized by muco-purulent discharge, 
and frequent urination, with imperfect cut off. On passing a bul- 
bous bougie narrowing is detected. 

Give the treatment of chronic urethral discharge. 

Urethral catarrh. Constitutional treatment, open air, nourish- 
ing diet, exercise, regular living, iodide of iron. 

Chronic gonorrhoea. Locate the spot by means of the bulbous 
bougie. Apply, by means of the prostatic syringe, a one-quarter 
per cent, solution of nitrate of silver, increasing the strength if 
there is no pain ; follow by astringents, zinc or copper. Irriga- 
tion with hot solution of permanganate of potash (1 : 2000). 

Gleet. Gradual dilatation with steel sounds, passed twice 
weekly, till the urethra is of normal size (28 to 32, depending on 
the size of the penis). 

Give the treatment for complications of gonorrhoea. 

Balanitis. Wash carefully four times daily, and dust with 
iodol, iodoform, or a powder of bismuth and opium. 

Balano-posthitis. Careful washing. If great swelling, envelop 
in lead water and laudanum. 

Phimosis. Injections beneath the prepuce of soap and water, 
then water, finally lead water and laudanum ; wrap the penis 
in cloths wet in lead water and laudanum. Incision or circum- 
cision may be necessary. 

Paraphimosis. Reduce by manipulating, or, covering the 
glans with lint, envelop it from before backward in an elastic 



218 



ESSENTIALS OF SURGERY. 



band, slip a director under the constriction, remove the elastic 
wrapping, and reduction may be effected. Incision if other means 
fail. 

Prostatitis, cystitis (see under these headings). 

Epididymitis. Best in bed, elevation of scrotum, application 
of evaporating lotions, abstraction of six or eight ounces of blood 



Fig. 49. 



Fig. 50. 





R. R. The constricting ring in 
paraphimosis. 



R. R. The constricting ring in 
phimosis. 



by leeches placed over the cord. Open the bowels, give morphia 
hypodermically, bromide of potassium and aconite internally. 
If swelling increases and pain is intense, puncture the tunica 
albuginea with a tenotome. When acute inflammatory symp- 
toms begin to subside, strap the testicle. 

Gonorrhoeal rheumatism. Iodine and splint to the joint, to- 
gether with firm pressure ; very full doses of quinine (grains xl. 
daily), small doses of mercury, generous diet. 

Give the treatment of gonorrhoea in the female. 

Usual form, vulvo-vaginitis, may extend to the urethra, the 
womb, the Fallopian tubes (gonorrhoeal salpingitis), and the 
ovaries. 

Rest in bed, milk diet, free motion from the bowels, repeated 
daily washings with strong sod. bicarb, solutions, followed by 
thorough application of liq. argent, nit. grains lx to tbe ounce. 
General hot baths, or, in case of vaginitis, every two hours inject 



STRICTURE OF THE URETHRA. 219 

bicarbonate of soda solution, Oj, follow with aq., Oj, finally 
acetate of lead ^iij (teaspoonful) in the pint of water. Keep the 
mucous surfaces apart by packing with absorbent cotton con- 
taining lead acetate. 



Urethral Deformities. 

Describe epispadia. 

Epispadia, or deficiency of the urethral roof, may be complete 
or partial. Complete epispadia is usually associated with ex- 
strophy of the bladder. 

Treatment. Freshen the edges on either side of the urethral 
floor, and bring them together over a catheter by means of quill 
sutures ; flaps may be transplanted. 

Describe hypospadia. 

Hypospadia, or deficiency of the urethral floor, may occur at 
the base of the frenum, or at the junction of the penis and 
scrotum. 

Treatment. Restore the natural passage ; freshen the edges of 
the abnormal opening, and close or cover by transplanted flaps. 



Stricture of the Urethra. 

What is stricture of the urethra? 

True or organic stricture is permanent narrowing of the urethral 
canal at one or more places, due to disease, injury, or congenital 
defect. There are also spasmodic and congestive strictures. 

What are the causes of stricture ? 

Gonorrhoea, traumatism, ulceration, and masturbation. 

Give some varieties of organic urethral stricture. 

In regard to cause: 1. Idiopathic. 2. Traumatic. 3. In- 
flammatory. 

In regard to anatomical appearances — 

1. Bridle stricture. A band of lymph, attached only by its ends, 
stretching across the urethra. 



220 ESSEKTIALS OF SURGERY. 

2. Annular. A circular constriction as though a string were 
tied about the urethra. 

3. Indurated annular. 

4. Cartilaginous. 

In regard to the possibility of passing instruments strictures 
are classed as permeable and impermeable. 

In regard to their behavior on manipulation, they may be sim- 
ple, irritable, contractile or recurring. 

What are the favorite seats of stricture ? 

1. Anterior part of the urethra. 2. Just in front of the mem- 
branous portion of the urethra. Strictures are never found in 
the prostatic portion of the urethra. 

What are the consequences of an untreated stricture? 

Hyperemia and inflammation about the stricture. Dilation 
and thinning of the urethral walls behind. Hypersecretion and 
gleet. Ulceration majr take place, followed by extravasation, 
abscesses, and fistula?. From constant straining, bladder be- 
comes thickened, hypertrophied, and sacculated. Urine is 
retained and ferments ; cystitis may reach a high grade. The 
inflammation passes along the ureters, involves the pelves of 
the kidneys, and may cause death by suppurative pyelitis, or 
nephritis. 

What are the symptoms of organic strictures of the urethra? 

Gleety discharge, especially in the morning ; increased frequency 
of urination, with some pain, twisting, forking, or diminution in 
the size of the stream. Retention may be the first and only sign. 
Later symptoms are due to involvement of other organs ; hemor- 
rhoids frequently result from constant straining. 

How do you diagnose strictures ? 

By examination of the urethra with bulbous bougies. Com- 
mence with medium-sized bulbous bougie and increase the size 
till decided resistance is experienced ; or if the first tried will 
not pass, diminish the size till one finally enters the bladder, 
marking on its stem the point where resistance begins ; slowly 
withdraw from the bladder, marking again the point where 
resistance begins ; this will give both the calibre and the width 



STRICTURE OF THE URETHRA. 



221 



of the stricture. If the obstruction is more than six Fig. 51. 
inches from the meatus, it is probably an enlarged 
prostate. The possibility of spasm or the catching 
of the bulb of the bougie in a lacuna or at the tri- 
angular ligament must be borne in mind. 

What special points must be observed in passing a 
bougie or catheter ? 

1. See that the instrument is clean, smooth, and, 
if it is a catheter, pervious. 

2. Warm and oil. 

3. Place the patient on his back with thighs flexed. 

4. Bear in mind the course of the urethra, keep 
the catheter in the middle line, stretch the penis 
forward and upward, and use no force. 

What difficulties may occur in passing the catheter? 

1. It may catch in a fold of mucous membrane or 
in a lacuna. Avoid by keeping the point on the 
floor of the urethra at first, then along its roof. 

2. It may catch where the urethra enters the tri- 
angular ligament. Withdraw a little and keep the 
point of the instrument along the roof of the urethra. 

3. It may make a new false passage, or enter one 
already made. Denoted by a sudden slipping of the 
instrument, pain, and detection of the point of the 
catheter outside of the urethra by rectal examina- 
tion. The handle of the bougie is deflected from the 
middle line, no urine escapes, the point is not freely 
movable, and, if the false passage is recent, there will 
be free bleeding. 

How do you treat false passage ? 

Withdraw the instrument at once, and make no further effort 
to pass it for one or two weeks. Infiltration of urine rarely takes 
place, the passage healing promptly. 

What constitutional effects may follow the passage of an in- 
strument ? 

Hematuria, due to reflex congestion, syncope, rigors, urethral 
fever, suppression of urine, pyaemia. 



Bulbous 
bougie. 



222 



ESSENTIALS OF SURGERY. 



How may the danger from these sequelae be lessened? 

Pass instrument with the patient in the recumbent position ; 
give 12 grains of quinine an hour before treating; inject U[x 
to xx of a 1 per cent, solution of cocaine into the bulbous por- 
tion of the urethra by means of 
Fig. 52. Fig. 53. ^ ne prostatic syringe a few min- 

utes before passing an instru- 
ment. Keep the patient in bed 
six to twenty-four hours after 
the instrument is used. 

How do yon treat strictures? 

Strictures may be treated by 
— 1. Dilatation. This may be 
intermittent, continuous, or forci- 
ble (splitting). 2. Urethrotomy, 
or cutting ; either internal or ex- 
ternal. 3. Excision. 4. Electro- 
lysis. 

How do you get through a tight 
stricture ? 

Try a small, soft, olive-point- 
ed catheter or a small steel 
sound. That failing, electro- 
lysis may succeed. Finally sev- 
eral filiforms should be passed 
into the urethra, and each ma- 
nipulated in turn till one passes 
into the bladder ; this may be 
threaded upon a railroad cathe- 
ter and the latter forced through the stricture with- 
out fear of making a false passage. 

Describe intermittent dilatation. 

The calibre of the stricture having been determined, 
the largest flexible bougie which will pass through it 
is introduced, and allowed to remain in the urethra 
for four or five minutes before withdrawing. At the 




Filiform threaded 
upon a railroad cath- 
eter. 



Olive- 
pointed 

soft 
catheter. 



STRICTURE OF THE URETHRA 



223 



next attempt a larger instrument is used, till 28 to 30 French 
will readily pass in ; three days should elapse between each 
dilation. This is the best and safest of all methods of treat- 
ment for the simple forms of stricture. 

Describe continuous dilatation. 



The patient is put to bed ; a flexible ca- 
theter is passed through the stricture into 
the bladder, and allowed to remain for one 
or two days, when it is replaced by a larger 
one; continue in this way till the stric- 
ture is fully dilated. 

Under what circumstances may continu- 
ous dilatation be employed? 

Where there is great difficulty in pass- 
ing an instrument, or where the stricture 
is irritable or contractile. 

(The majority of surgeons condemn 
rapid dilatation or splitting.) 

Describe internal urethrotomy. 

By means of a guarded knife the stric- 
ture is cut entirely through. In tight stric- 
tures a guide or small instrument is passed, 
which can be threaded on the urethrotome, 
and the latter can then be made to cut its 
way inward without fear of its going 
astray. Pass a bulbous bougie to see that 
the stricture has been completely divided, 
in which case there is no fear of urinary 
extravasation. In four days pass a full- 
sized soft catheter. 

What strictures are properly subject to 
internal urethrotomy? 

Strictures in front of the scrotum, and 
contractile, irritable, and cartilaginous 
strictures. 



Fig. 54. 



Railroad urethrotome. 
(White.) 



224 



ESSENTIALS OF SURGERY 



Fig. 55. 




Describe external perineal urethrotomy with a guide (Syme's 
method). 

Lithotomy position. The groove of a Syme's staff is passed 
through the stricture till its shoulder is caught in the beginning 
of the narrowing. A 1^ inch incision is made 
in the median line of the perineum, the groove 
of the staff is found, the knife slipped into it 
behind the stricture, and the latter divided by 
pressing the cutting edge forward. A director 
is passed into the bladder, and a 14 (English) 
soft-rubber catheter passed per urethram. 
This catheter is not left in, but is passed every 
three or four days till the wound is healed. 

What strictures call for external perineal ure- 
throtomy with a guide? 

Dense cartilaginous strictures, or irritable 
and contractile strictures when complicated by 
perineal fistulse. 

How do you treat impermeable strictures ? 

By Wheelhouses's modification of perineal 
section. 

By Cock's operation of perineal section, or 
tapping the urethra at the apex of the prostate. 

What is Wheelhouses's modification of perineal 
section? 

The urethra is opened half an inch in front 

of the stricture, when the latter can be exposed 

to view, entered by a probe, and divided. A 

broad director introduced into the bladder 

Syme's staff. guides a flexible catheter passed through the 

meatus. The catheter is left in for three or 

four days. In this operation the Wheelhouses staff is used ; this 

is practically a director, grooved to within half an inch of its 

end, and terminating in a blunt-hooked projection. 



STRICTURE OF THE URETHRA. 225 

What are the indications for Wheelhouses's modification of 
perineal section ? 
Dense cartilaginous, or irritable and contractile strictures, 
which are impermeable. 

Describe Cock's perineal section. 

Lithotomy position. Left forefinger in rectum, the point ap- 
plied to apex of prostate. Pass a long, straight knife, with its 
back towards the rectum, in the middle line beneath the bulb, 
so that it may enter the membranous portion of the urethra ; a 
director is then introduced, and guided by it a soft catheter is 
passed into the bladder. The urethra is opened behind the 
stricture, the latter not being touched. 

Indicated in case of impermeable stricture complicated by 
urinary retention, or in case of urethral rupture. 

Describe rnptnre of the urethra. 

Cause. Violence. May be torn partly or completely across. 
Seats. Just in front of, or just behind the triangular liga- 
ment. 

Give the symptoms of ruptured urethra. 

Behind triangular ligament as in rupture of bladder. Inability 
to pass water. Blood and urine on catheterization. Infiltration 
behind symphysis. 

In front of triangular ligament. Tumor in perineum ; blood 
per urethram ; inability to pass water. 

How do you treat ruptured urethra ? 

Pass in a catheter. If there is any difficulty in introducing, 
do an external perineal urethrotomy, passing a catheter after 
two or three days, and at regular intervals afterwards. If ure- 
thra completely torn across, unite by catgut suture. 

Describe urinary extravasation. 

If extravasation takes place from the prostatic portion of the 
urethra, the symptoms and treatment are the same as for rup- 
tured bladder. If from the membranous portion, there will be 
at first a hard lump in the perineum, as the anterior layer of the 
triangular ligament gives way, the extravasation will take the 
15 



226 ESSENTIALS OF SURGERY. 

course common in all anterior extravasations, that is, into the 
scrotum and up upon the abdominal parietes, not descending 
upon the thighs (attachments of deep layer of superficial fascia). 
The symptoms are characteristic ; if the patient has been suffer- 
ing from retention, he may suddenly experience a sense of 
relief, followed shortly by burning pain in the perineum and in- 
flammatory fever, which quickly becomes typhoid in type. There 
are redness, swelling, oedema, and early sloughing of the infil- 
trated area. 

The treatment is perineal section, tapping the source of extrava- 
sation. Long incision should follow up the subcutaneous infil- 
tration. 



Diseases of the Prostate. 

Name the surgical affections of the prostate gland. 

Inflammation; may be acute, chronic, or complicated by 
abscess. Hypertrophy. Atrophy. Tubercle. Malignant disease, 
sarcoma in the young, carcinoma in the old. 

Give the symptoms of acute inflammation of the prostate. 

Usual cause — gonorrhoea or stricture. 

There is pain at the neck of the bladder, increased by defecation 
and by micturition, especially towards the end of the act. 

The water is passed frequently . On examination per rectum the 
prostate is felt as a hot, tender enlargement. There is fever. 

Termination. Eesolution, abscess, or chronic inflammation. 

Give the treatment of acute prostatitis. 

Open bowels freely. Render the urine bland by full doses of 
alkaline carbonates. Apply leeches to the perineum, followed 
by hot fomentations, poultices, and hot hip-baths. If there is re- 
tention, a catheter should be passed. If an abscess forms, open 
the perineum in the middle line. 

Describe chronic prostatitis. 

Causes. An acute attack, stricture, masturbation, gout. 
It is characterized by constant aching pain in the perineum, 
aggravated by defecation and urination. There is a discharge. 



DISEASES OF THE PROSTATE. 227 

like the white of an egg, appearing during defecation and at the 
beginning of urination. There is frequent urination with imper- 
fect cut off, and cystitis. 

Treatment. Avoidance of stimulants, sexual indulgence, or 
violent exercise. Bowels must be kept open. Tonics. Sea 
bathing. Fugitive blisters to perineum. By means of the pros- 
tatic syringe nitrate of silver, TTLv of a two per cent, solution, 
applied to the diseased area. 

Give the symptoms of enlarged prostate. 

This is a disease of advanced life. It is characterized by 
greatly increased frequency of micturition, especially at night, 
by loss of force in the stream, with difficulty and slotcness in start- 
ing it, by a sense of fulness about the rectum. Yery frequently 
there are hemorrhoids from straining. Fermentation of retained 
urine with cystitis may follow. Finally, retention with overflow, 
or even absolute retention may result. 

How do you diagnose an enlargement of the prostate ? 

The finger in the rectum will recognize most enlargements. 
In case there is projection of the middle lobe into the urethra 
a silver catheter will meet with an obstruction, more than seven 
inches from the meatus, which is only overcome by greatly de- 
pressing the handle of the instrument. An ordinary catheter 
may not be long enough to reach the bladder. 

How do you treat chronic enlargement of the prostate ? 

Immediately after urination pass a soft catheter. If addi- 
tional water can be drawn, it is proof that the obstruction pre- 
vents thorough emptying of the bladder. Give the patient a 
soft catheter, elbowed if the middle lobe is enlarged, and let 
him pass it every night on retiring. Commence this treat- 
ment before cystitis appears. For more aggravated cases do 
White's operation of orchidectomy or vasectomy. In some 
cases, when the bladder is irritable and sacculated, the pain 
unbearable, the patient absolutely unable to pass water with- 
out a catheter, but suffering intensely each time the instru- 
ment is passed, it may be necessary to drain the bladder by — 
1. Perineal section. 2. Suprapubic tapping and retention of 



228 ESSENTIALS OF SURGERY. 

carmla. 3. Suprapubic incision with excision of a portion of 
the prostate. 

What symptoms denote malignant disease of the prostate? 

Pain, frequent urination, hemorrhage per urethram, shreds 
of growth in urine, rapid swelling of unequal consistency, gland- 
ular enlargements, cachexia. 

Treatment. Palliative. 

What is meant by bar at the neck of the bladder? 

A ridge due to hypertrophy of the lateral lobes. 



AFFECTIONS OF THE BLADDER. 229 

t 

AFFECTIONS OF THE BLADDER. 

Rupture of the Bladder. 

Describe rupture of the bladder. {See also p. 101 .) 

Causes. Violence. Over-distension. May be intra- or extra-peri- 
toneal. 

Symptoms. Pain and collapse, sense of something giving way, 
urgent desire to urinate without the power to do so, rapid devel- 
opment of inflammation or peritonitis. Catheter passed just in- 
side the bladder draws blood only, or a small amount of bloody 
urine. If the patient has passed his urine immediately before 
the accident, a weak antiseptic solution (boracic acid) may be 
injected into the bladder. If there is a rupture, it cannot be 
again drawn off. 

Treatment. Insertion of full-sized catheter and expectant, or 
Suprapubic Cystotomy; opening and washing out the peritoneal 
cavity if urine has been extravasated into it, closing the peri- 
toneal rent, and inserting a drainage tube. After treatment, 
patient in lateral decubitus. 

What tumors are found in the bladder ? 

Papilloma — most common benign tumor. Mucous and fibrous 
polyps, rare. Sarcoma. Carcinoma, epithelial or encephaloid. 
Tumors are usually situated on the trigone. 

Give the symptoms of bladder tumor. 

Hematuria, cystitis, pain, the passage per urethram of frag- 
ments of the growth. 

Treatment. Benign growths may be removed by perineal or 
suprapubic operations. 

Exstrophy of the Bladder. 

What is exstrophy of the bladder ? 

Synonyms. Ectopion, extroversion. 

Definition. Congenital absence of the anterior wall of the 



230 ESSENTIALS OF SURGERY. 

bladder, together with the corresponding portion of the abdomi- 
nal wall. The posterior wall of the bladder projects as a round, 
vascular, red, ulcerated tumor, covered with mucous membrane, 
and exposing the orifices of the ureters. 

Treatment consists in covering in the defect by deep and super- 
ficial flaps, which have their raw surfaces apposed, and offer 
both to the bladder wall and externally, skin surfaces. 

This deformity is usually accompanied by epispadia. 

Cystitis, 

What are the causes of cystitis? 

Cystitis, or inflammation of the bladder, may be acute or 
chronic. 

Causes. Mechanical or chemical injury, or direct extension 
(gonorrhoea). 

Give the symptoms of acute cystitis. 

Pain, burning, may be very severe, located in the bladder and 
perineum. Strangury, a continual desire to void urine, which 
is spasmodically passed, a few drops at a time. Tenderness, well 
marked over the pubes, in the bladder region. Urine, scanty, 
highly colored, containing mucus, blood, and pus. Fever, directly 
proportionate to the grade of inflammation. 

Give the treatment of acute cystitis. 

Rest in bed. Diet of skimmed milk, with carbonated drinks. 
Bowels soluble. Leeches to perineum, or over pubes. Hot hip- 
baths and hot poultices. Alkaline carbonates, hyoscyamus, morphia 
and belladonna suppository. If urine is ammoniacal, the bladder 
must be washed out with antiseptic lotions (boracic acid gr. iv 
to gj); this failing, an external perineal urethrotomy with 
drainage of the bladder is indicated. 

Describe chronic cystitis. 

Symptoms as in acute, but milder. Urine often ammoniacal, 
very offensive, contains large quantities of ropy mucus and pus. 
Mucous membrane thickened, congested, ulcerated. Muscular 
coat thickened, fasciculated, giving the interior of the bladder a 



AFFECTIONS OF THE BLADDER. 231 

ridged appearance. Between the muscular ridges the mucous 
membrane may he forced outward by constant straining, form- 
ing sacculations, in which stones may form. 

Treatment. Kemoval of cause, where possible. General 
hygiene. Milk diet, with free use of non-stimulating drinks. 
Triticum repens, uva ursi, copaiba, cubebs. When urine alka- 
line, benzoic acid. Load washinys. Twice daily with boracic 
acid, or water hot as it can be borne. In severe cases, perineal 
cystotomy and drainage. 

Atony and Paralysis of the Bladder. 

What is atony of the bladder ? 

By atony is implied a loss of tone in the muscular fibres of 
the bladder, making it unable to expel its contents. The blad- 
der is only partially emptied at each micturition ; it gradually 
becomes more and more full till the condition known as reten- 
tion with overflow is developed, simulating incontinence. The 
cause of atony is over-distension ; it may arise in the course of 
low fever, from voluntary neglect, or from urethral obstruction. 

Treatment. Catheter ; cold douche to bladder and to lumbar 
spine. 

Describe paralysis of the bladder. 

Cause. Injury, or organic disease of nervous system, nervous 
exhaustion. If the neck of the bladder is affected, it causes 
incontinence. If the body of the bladder alone is involved, there 
will be retention. 

Treatment. Catheter, tonics, strychnia, electricity. 



Haematuria. 

How can you determine the source of blood in the urine? 

From the kidney. Blood is uniformly distributed through the 
urine. From the bladder. Comparatively clear urine is passed 
at first, followed by blood. From the urethra. Blood passes first^ 
then urine. 



232 ESSENTIALS OF SURGERY. 

What surgical affections may cause renal hemorrhage ? 

Contusion or jarring, congestion, inflammation, calculus, the 
uric acid diathesis, catheterism, malignant disease. 

Give the causes of bladder hemorrhages. 

Traumatism, calculus, inflammation, new growths. 

Give the causes of urethral hemorrhages. 

Injury, ulceration, calculus, erectile growths. 

How are clots removed from the bladder? 

By large suction catheter. By digesting the clots in the blad- 
der. By urethrotomy or cystotomy. 



Retention of Urine. 

What are the causes of retention of urine ? 

Retention means simply inability to pass the urine from th 
bladder. Suppression means absence of the secretion. 
The causes of retention are — 

1. Impacted calculus or foreign body. 

2. Alterations in the urethral walls, either permanent, as stric- 
ture and enlarged prostate, ov temporary, as congestion and spasm. 

3. Pressure from without the urethra, as in case of certain 
tumors. 

4. Atony or paralysis of the bladder. 

In retention due to stricture, the acute condition is generally 
brought about by an added spasm or congestion due to excesses 
or exposure. 

After operations or injury, spasmodic retention is especially 
liable to occur. 

Give the symptoms and signs of retention. 

If the condition comes on slowly, the bladder may become 
enormously distended, with few local or constitutional signs other 
than those connected with urethral obstruction. Finally the 
urine dribbles away as fast as secreted, the bladder still remain- 
ing full. This constitutes the condition known as retention with 
overflow, and is diagnosed by outlining the full bladder by means 
of abdominal percussion, and bypassing a catheter. 



AFFECTIONS OF THE BLADDER. 



233 




Prostatic catheter. 



Betention due to organic stricture. Attempt to pass 
a soft catheter or filiform, failing, give opium per 
rectum, and hot bath. If the urine is still not 
passed, anaesthetize and again attempt to pass an 



5G. 



In sudden and complete retention there is intense local pain, with 
rapid development of constitutional symptoms of a typhoid type. 

The bladder, unless greatly stiffened and altered b}' previous 
inflammation, rises out of the pelvis, and can be readily detected 
Iry abdominal examination. 

What are the consequences of retention ? f: 

Atony, cystitis, nephritis, rupture of either the 
bladder, or of the urethra behind a point of obstruc- 
tion, or retention with overflow. 

Give the treatment of retention of urine. 

If the symptoms are urgent, immediate catheteri- 
zation. 

Betention due to spasmodic and congestive strictures. 

Spasm and congestion are rarely sufficient in 
themselves to cause retention ; they are usually as- 
sociated with slight stricture or enlargement of 
prostate, and are brought on by exposure, debauch, 
or operation. 

Treatment. Hot bath, and full dose of tr. opii 
(TTLxxx) by the rectum. If there is no spontaneous 
relief, pass a catheter. Open the bowels, and keep 
the urine unirritating. 

Fig. 57. 



I 



Mercier's 
elbowed ca- 
theter. 



234 ESSENTIALS OF SURGERY. 

instrument ; if unsuccessful, either incise, or make a suprapubic 
aspiration or puncture. 

Retention due to hypertrophy of prostate. Usually due to con- 
gestion (congestive stricture), it is induced by debauch, etc. 
Try the elbowed catheter, the flexible catheter with stylet, which 
is somewhat withdrawn when the beak impinges on the prostate, 
the silver prostatic catheter. If passed with much difficulty, 
leave in. If bladder very full, draw off only a part of the urine 
(to avoid syncope and hemorrhage). Catheterization failing, 
do not try to relax, but immediately puncture, or aspirate above 
the pubes. 

Retention due to atony and paralysis of the bladder (usually re- 
tention with overflow). Regular use of soft catheter. 

Describe suprapubic tapping of the bladder. 

Trocar and canula, full-sized, and with a marked curve, thrust 
through the abdominal w r all just above the pubes and into the 
bladder beneath the peritoneal reflection. The trocar is with- 
drawn, and a rubber tube is passed through the canula and left 
in. In three or four days the tube is withdrawn, leaving a short 
sinus into the bladder, which may be kept open indefinitely. 

When temporary relief is sought from retention, aspirate in the 
same region. Tapping may also be done through the pubes, 
through the perineum, through the rectum. 

What are the varieties of incontinence of urine? 

True incontinence. The urine dribbles away as fast as secreted. 
Due to either enlargement of the middle lobe of the prostate, or 
disease or injury involving the lumbar cord. 

Hocturnal incontinence. Due to an abnormal reflex sensibility. 
Slight irritation, such as might be caused by worms or phimosis, 
causes micturition. 

Treatment. For nocturnal incontinence, lateral decubitus, and 
regular emptying of the bladder once or twice during the night. 
Sponge baths night and morning, belladonna pushed to its physi- 
ological limit. 



AFFECTIONS OF THE BLADDER. 235 



Stone in the Bladder. 

What are the common varieties of calculus ? 

Uric acid. Oxalate of lime. Phosphatic salts. Among the less 
common varieties are the stones made up of urates, cystin, 
xanthin. Calculi are formed of concentric -laminae, frequently 
made up of different materials (alternating calculi). They may 
be single or multiple, free or encysted, only one surface, in the 
latter case, being subject to deposit. 

How may you infer the nature of a stone ? 
By an examination of the urinary sediment. 

How may stone terminate ? 

In cystitis, pyelitis, nephritis. 

Give the symptoms of stone in the bladder. 

Fain. Chronic, aggravated hj motion and jarring, felt across 
the loins and down the thighs ; also anaczrfe pain, referred to the 
end of the penis, and most intense towards the termination of 
micturition (the stone falls on the sensitive trigone and the 
bladder walls contract upon it). 

Increased frequency of micturition during the day, or while the 
patient is moving about. 

Hcematuria. Slight, following micturition. 

Sudden stoppage of the stream while micturating. Cystitis. 
Piles in adults. Elongated prepuce in boys (from pulling). 
Prolapse of rectum in children. 

How do you diagnose cystic calculus ? ' 

Pass into the bladder a solid or hollow sound with a sharply 
curved bulbous beak. Insert a finger into the rectum. By 
manipulating the instrument, and turning it towards all portions 
of the bladder, the stone may be struck. The click of the sound 
against the calculus should be both heard and felt. 

Under what circumstances may careful sounding fail to detect 
stone? 

When the stone is encysted, or when it is coated with blood 
and mucus. If symptoms point to stone, sound repeatedly. 



236 



ESSENTIALS OF SURGERY 



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AFFECTIONS OF THE BLADDER. 237 

How may vesical calculi be treated ? 

By Litholysis or solvent treatment, practically useless in treat- 
ing bladder stones. Lithotrity, or crushing the stone in the 
bladder. Litholapaxy, or crushing and washing out at one 
sitting. Lithotomy, or cutting into the bladder and removing 
the stone. 

What circumstances guide you in the choice of operation? 

Litholapaxy, in adults as a rule. 
Lithotomy is indicated. 

1.. In children, because the urethra is small, the bladder lies 
high, and lithotomy has given the best statistics. 

2. For large hard stones, an oxalate stone with maximum 
diameter greater than one inch would indicate the cutting 
operation. 

3. In case of marked urethral stricture. 

4. In aggravated cystitis or sacadation of bladder. The incision, 
by providing drainage, would greatly ameliorate the bladder 
disease. 

5. In irritable urethra, with tendency to urethral fever. 

Mention some sequelae of litholapaxy. 

Rigors and fever, retention of urine, cystitis or prostatitis, 
hemorrhage, suppression of urine, phlebitis, and pyaemia. If 
death occurs, it is mostly due to the chronic kidney trouble. 

Describe lithotomy. 

May be Perineal. (1. Lateral. 2. Median. 3. Bilateral.) 
Becio-vesical. Suprapubic. 

Usual operation. Lateral perineal. Prepare the patient by 
rest in bed, a laxative the night before, an injection the morn- 
ing of operation. Anaesthetize, draw the urine, and inject six 
ounces of warm water. Pass into the bladder a full-sized 
grooved staff and strike the stone. If it is not found, withdraw 
the staff and pass a sound. Failing to strike it with this, the 
operation should be postponed. If the stone is found, place the 
patient in lithotomy position, the soles of the feet being grasped 
in the palms of the hands, and secured by shackles or band- 
ages in this position ; bring the nates down over the end of the 



238 ESSENTIALS OF SURGERY. 

table, let an assistant hold the staff directly in the middle 
line hooked under the pubes, while the operator, seated facing 
the buttocks, passes the finger of his left hand into the rectum, 
and, with the knife in his right hand, makes an incision midway 
between the scrotum and anus, and just to the left of the mid- 
dle line, downward and outward to below the anus and some- 
what nearer the tuberosity of the ischium than to this opening. 
The incision divides skin, superficial fascia, external hemor- 
rhoidal and superficial perineal vessels, and the correspond- 
ing nerves. Deepen the wound, cutting transversus peronei 
muscle and artery, the lower border of the triangular liga- 
ment, and, possibly, some fibres of the accelerator urinse. 
Search with the disinfected finger of the left hand for the staff, 
place the point of the knife in the groove, dividing the compres- 
sor urethral and membranous portion of the urethra. Turn 
the blade somewhat toward the patient's left (the longest dia- 
meter of the prostate), and push it through the levator pros- 
tata3, and the gland itself, till it enters the bladder. Withdraw 
the knife, and twist the finger along the concave surface of the 
staff into the bladder. When the stone is touched and the staff 
taken out, pass the forceps along the finger ; on withdrawing 
the latter, there will be a rush of water, which commonly car- 
ries the stone into the grasp of the instrument. See that the 
stone is grasped with its smallest diameter presenting, and 
exert traction in the axis of the pelvis. Encysted calculi must 
be removed by the finger and a scoop. 

Apply no dressing ; simply dust with iodoform. Urine comes 
through the lithotomy wound for two days, then from the 
urethra, owing to swelling ; as inflammation subsides it again 
flows from the wound. Put the patient in bed, on his back, and 
with a rubber bed-pan to receive the urine. 

What accidents may occur in lateral lithotomy? 

Hemorrhage, from a wounded artery, or from the prostatic 
plexus. 

Treatment. Tie the bleeding point. If that cannot be accom- 
plished, haemostatic forceps, or acupressure. Venous hemor- 
rhage may take place some hours after the operation, the blood 



AFFECTIONS OF THE BLADDER. 239 

flowing into the bladder ; in which case wash out all coagula, and 
check the hemorrhage by a petticoated tube packed with lint. 

Other less common accidents are, wound of rectum, wound of 
bladder, and tearing the urethra across, the latter complication 
especially liable to occur in children. If the urethra is pushed 
off the staff, the operation must be abandoned. 

Mention some causes of death after lithotomy. 

Infiltration of urine, from opening of recto-vesical fascia ; dif- 
fuse inflammation, from bruising ; hemorrhage, pyaemia, peritoni- 
tis, shock, cystitis, suppression of urine. 

Describe median lithotomy. 

Pass a grooved staff as before. Feel the apex of the prostate 
with the finger in the rectum. Make an incision in the median 
line of the perineum, beginning ^ inch from the anus, and pass 
the point of the knife into the groove of the staff, nicking the 
apex of the prostate and dividing the membranous portion of 
the urethra. 

What are the indications for median lithotomy ? 

Small stones, foreign bodies, exploratory incisions. 

Describe suprapubic lithotomy. 

This operation consists in opening the anterior wall of the 
bladder, below the peritoneal reflection. 

Position. On the back, with the buttocks elevated. Inflate 
the rectum moderately, by means of a rubber bag distended with 
air or water. Draw the urine, and inject four to six ounces of 
boracic acid solution into the bladder. Incision through the 
linea alba, immediately above the symphysis. Tear through the 
fibrous and fatty tissues till the wall of the bladder is exposed. 
Draw the peritoneal reflection upward. Incise below its attach- 
ment. Enlarge, if necessary, by tearing, and extract the stone. 
The patient maintains the lateral decubitus, changing from one 
side to the other. This drains the bladder. A rubber air-cushion 
is arranged to receive the urine. 

What are the indications for suprapubic lithotomy ? 

Large, hard stones, of a greater diameter than one-and-a-half 
inches. 



240 ESSENTIALS OF SURGERY. 

This method of cystotomy is also advised in cases of tumor of 
the bladder. Many surgeons consider this operation as prefera- 
ble in nearly all cases where the bladder has to be opened. 

What are the symptoms of calculus impacted in the urethra ? 

Sudden stoppage of the stream, great pain, a drop or two of 
blood, and retention of urine. 

Treatment. If possible, work it forward along the urethra, 
grasp and extract with urethral forceps. Stretch the skin over 
it and extract by a small incision, letting the wound granulate. 
If at the neck of the bladder, do a median lithotomy. 

Hydrocele. 

Name the varieties of hydrocele. 

1. Vaginal hydrocele. This is the common variety ; the 
serous effusion is in the tunica vaginalis testis. Hydrocele im- 
plies this form. 

2. Congenital hydrocele. Arises from an imperfect closure of 
the communication between the peritoneal cavity and the tunica 
vaginalis. 

3. Encysted hydrocele of the testis or epididymis. Keally cystic 
growths from these structures. The fluid is often opalescent 
and contains spermatozoa. 

4. Encysted hydrocele of the cord. A serous effusion into an 
unobliterated portion of the funicular part of the tunica vagi- 
nalis. 

What are the symptoms of hydrocele? 

A smooth, tense, elastic, fluctuating swelling in the scrotum; 
of pyriform shape, and translucent. The testicle lies behind it and 
near its lower part. 

In congenital hydrocele the effusion can be slowly pressed 
back into the peritoneal cavity, to reappear when pressure is 
removed. 

Give the treatment of hydrocele. 

Palliative. Discutient remedies (especially in the congenital 
form), such as muriate of ammonia 3ss to aq. ^j, or weak solu- 



HYDROCELE. 241 

tions of iodine. Tapping and draining off the fluid by trocar 
and canula. 

Radical. Tapping and injection of iodine. Incision, drain- 
age, and antiseptic dressing. Excision of sac. Tapping with 
injection is dangerous. 

Describe tapping a hydrocele. 

See that the trocar and canula are clean, and movable on each 
other. Determine the position of the testicle. Grasp the 
enlargement with the left hand, making its anterior portion 
tense. Thrust the trocar directly backward, turning it upward 
as soon as it has entered the sac. Evacuate the fluid, withdraw 
the canula, and close the wound with iodoform collodion. 

If the hydrocele is to be radically cured, inject, after draining 
the fluid, tr. iodin. £ij, and manipulate the scrotum so that the 
injection may come in contact with every portion of the sac 
walls. Withdraw the canula, and close the wound as before. 
Acute inflammation shortly follows, and the swelling may even 
exceed its original extent. It shortly subsides, obliterating the 
cavity by inflammatory adhesions. 

The safest operation is that of Hearn. Make a small incision, 
catch the edges of the sac with forceps, dry its interior with 
gauze, swab out with pure carbolic acid, pack for 24 hours with 
iodoform gauze, and allow it to heal. 

Hematocele. 

What is hematocele ? 

An effusion of blood into the tunica vaginalis testis. Strictly, 
the term includes effusion in connection with either testis or 
cord, as in case of hydrocele. 

What are the causes of hematocele ? 

Traumatism, or spontaneous rupture of diseased bloodvessels. 

How do you diagnose hematocele? 

A smooth, tense, semifluctuating, pyriform swelling appears 
rather suddenly. It is opaque by transmitted light, gives to the 
exploring needle disorganized blood, and is often accompanied 
by considerable ecchymosis of the scrotum. 
16 



242 ESSENTIALS OF SURGERY. 

Give the treatment of hematocele. 

If recent, rest in bed, elevation, and application of cold. If 
this fails, incise and evacuate. 

Varicocele. 

What is varicocele ? 

A varicose condition of the pampiniform plexus. 

Why is varicocele commonly found on the left side ? 

1. The left spermatic vein is longer. 2. It opens into the 
renal vein at right angles to the blood-current. 3. It is crossed 
by the sigmoid flexure, and hence subject to pressure from feecal 
accumulations. 

What are the symptoms of varicocele? 

Dragging pain and discomfort, relieved by recumbency. 
Considerable mental depression. On examination there is found 
a soft, knotted, irregular, opaque, pyriform tumor, feeling like a 
bunch of earth-worms; it gives an impulse on coughing, and 
gradually disappears on lying down. 

Give the treatment of varicocele. 

General hygiene, regular exercise, cold sponging, and local 
douches. The bowels should be regulated, and a suspensory 
bandage worn, with a ring through which a portion of the scro- 
tum can be drawn. 

Radical. Subcutaneous ligation or acupressure. Excision 
by the open method is the best operation. 

Sarcocele. 

Name the surgical affections of the testicle. 

Epididymitis and orchitis, acute or chronic. Syphilitic, tuber- 
cidar, cystic, or malignant disease. All these enlargements may 
be accompanied by hydrocele. 

What is sarcocele? 

A term applied to all solid enlargements of the testes, hence 
we have simple, tubercular, malignant sarcocele, etc. 

(For acute epididymitis see pages 213, 216. Acute orchitis has 
the same symptomatology and treatment.) 



SARCOCELE. 243 

Describe simple sarcocele. 

Due to simple chronic orchitis. It is simply an overgrowth 
of the connective tissue, following an acute attack of inflamma- 
tion ; forming a smooth, hard, non-sensitive enlargement. Tes- 
ticular sensation may ultimately disappear. This indicates 
atrophy of the secreting tissues. 

Treatment. Strap. 

Describe syphilitic sarcocele. 

Pathology. Either a diffused or localized induration (gumma). 
The testicle, at first smooth and globular, becomes nodular, of 
stony hardness, and non-sensitive. The tumor preserves its gene- 
ral ovoid outline. 

Treatment. Strapping and constitutional medication. 

Describe tubercular disease of the testicle. 

The diagnostic points of tubercular sarcocele are : It occurs in 
the young adult, whose family history is frequently strumous, 
it is indolent and slow in development, the epididymis is first 
attacked, there is rarely hydrocele, the vas deferens is thick- 
ened, and the induration is prone to break down. 

Treatment. Constitutional. Total ablation of diseased area. 
Castratijon if necessary. 

Describe fibro-cystic disease of the testes. 

Occurs in old men, and is a gradual, painless, unilateral en- 
largement, attended with absence of testicular sensation, and 
presenting no history of previous injury or inflammation. 

Treatment. Castration. 

Describe malignant disease of the testicle. 

Sarcoma, most common, small round-celled. Carcinoma, usu- 
ally encephaloid. The diagnosis from fibro-cystic disease is 
made by the exceeding rapidity of the growth, which involves 
the skin and ulcerates. All the signs of malignant disease are 
present. 



244 ESSENTIALS OF SURGERY. 



DISEASES OF VEINS. 

What is thrombosis? 

A clot formed in a vessel during life. 

What are the causes of venous thrombosis? 

1. Inflammation, injury, or degeneration of the walls of a 
vein. 

2. Alteration in the blood, blood stasis, or exhaustion. 

What becomes of a thrombus ? 

It may organize, it may calcify, forming phleboliths, or it 
may undergo red or yellow (septic) softening. 

What are the symptoms of thrombosis ? 

(Edema, and the detection of a tender, knotted, cord-like 
swelling in the course of a vein. There is pain on motion. 

How do you treat thrombosis? 

Rest and elevation. Mercury and belladonna ointment thickly 
applied, hot fomentations. Clear the bowels by a saline cathartic, 
give a simple but nourishing diet, and administer iron and 
quinine. Subsequently apply a pressure bandage, and use fric- 
tion and massage. 

What are the causes of phlebitis? 

Traumatism, thrombosis, gout, micro-organisms. 

What are the symptoms of phlebitis? 

A dusky red line in the course of the vein, and the symptoms 
of thrombosis. Treatment as for thrombosis. 

Describe suppurative phlebitis. 

Cause. Septic micro-organisms. 

Symptoms. As for phlebitis and thrombosis. Local inflam- 
matory signs are more marked ; there are frequently softening 
and suppuration in the course of the vein, and constitutional 
symptoms and metastatic abscesses indicate the development of 
pyaemia. 

Prognosis. Unfavorable, 



DISEASES OP VEINS. 245 

Treatment. If possible, ligation above and below the clot. 
Local disinfection and opening of abscesses. Amputation in 
some cases. 

What is a varix ? 

A permanent dilatation of a vein. The vein is said to be 
varicose. 

What are the causes of varicose veins ? 

Increased intravenous pressure from mechanical compression, 
from violent muscular contractions emptying the deep veins into 
the superficial, from long standing. Alteration in the vein 
walls. 

What are the symptoms of varix? 

Aching pains, and a sense of fulness after standing, together 
with the enlargement evident to the sight and touch. Muscular 
cramps are said to characterize deep varix. 

How do you treat varicose veins ? 

Palliative. As much rest and elevation of the part as possible, 
the application of a rubber bandage or an elastic stocking, tonics, 
and laxatives. 

Radical. Ligature and excision of the varices or ligature and 
division of the internal saphenous vein at the junction of the 
upper and middle thirds of the thigh. Schede's plan of a cir- 
cular incision through the skin of the leg, entirely around the 
limb, a hand's breadth below the knee. 



246 ESSENTIALS OF SURGERY 



ANGIOMA. 

Describe the different varieties of angiomata. 

1. Arterial varix. A dilatation and lengthening of a single 
artery. 

2. Cirsoid aneurism. A tumor composed of a number of di- 
lated and tortuous arteries. 

3. Aneurism by anastomosis. A dilatation and lengthening, 
involving the arteries, capillaries, and lesser veins. 

4. Capillary ncevus. A dilatation and tortuosity involving the 
capillaries. 

5. Venous ncevus. A tumor composed of a number of inter- 
communicating spaces lined with endothelium, into which the 
arteries empty, and from which the veins take their origin. 

How do you treat angiomata ? 

Arterial varix, circoid aneurism, aneurism by anastomosis. Pro- 
tect. If rapidly extending, excise, cutting free of the involved 
area, and tying each artery as it is cut. Ligation of the main 
artery of the part, or injection of perchloride of iron may also 
be tried. 

Naivus. Very large superficial nsevi (port-wine marks), and 
those which are neither increasing in size nor produce visible 
deformity, should not be treated. Under other circumstances 
capillary ncevi may be removed by superficial cauterization, or 
incision, or escharotics lightly applied ; venous ncevi may be 
cured by incision, carried free of the diseased area ; by ligation, 
the thread being placed subcutaneously, or in an incision made 
through the skin ; by electrolysis, by coagulating injections. 



ANEURISM. 247 



ANEURISM. 

What is an aneurism ? 

A blood tumor communicating with the interior of an artery. 

Give the classification of aneurisms. 

1. Traumatic (see p. 74). 2. Spontaneous. 

a. Diffused. a. Tubular or fusiform. 

b. Circumscribed. b. Sacculated. 

c. Arterio-venous. c. Dissecting. 

The cirsoid aneurism and aneurism by anastomosis are, pro- 
perly, varieties of spontaneous aneurism. 

Describe spontaneous aneurism. 

Tubular or fusiform. A circumscribed dilatation of the whole 
circumference of the artery. The sac consists of all three coats. 

Sacculated. The dilatation involves a portion of the circum- 
ference only. The sac consists of the outer coat and of con- 
densed areolar tissue. May be circumscribed or diffused. 

Dissecting. The internal and a portion of the middle coat 
have yielded, the blood forcing its way between the layers of the 
middle coat. 

What are the causes of spontaneous aneurism? 

Predisposing. Atheroma, an embolus, leading to inflamma- 
tory softening. 

Exciting. Blows, strains, or sudden violent exertion. 

How may an aneurism terminate ? 

1. In spontaneous cure. 2. In death. 

Spontaneous cure may be effected by, 1, gradual consolidation 
by deposit of laminated clot ; 2, arterial occlusion above or below 
the sac by a fibrinous plug, or by the aneurism itself ; 3, inflam- 
mation of the sac and consequent clotting of the contained 
blood ; 4, suppuration and gangrene. Aneurism may cause 
death by pressure, by rupture and bleeding, by gangrene. 

What are the diagnostic signs of aneurism ? 

A tumor iK the course of an artery, diminished in size by 



248 ESSENTIALS OF SURGERY. 

pressure of the main artery above, increased in size by pressure 
upon the artery below. Characterized by thrill, bruit, and ex- 
pansile pulsation. The pulse in the artery below the aneurism 
is delayed in time, and more feeble than that of the opposite 
side of the body. There are various pressure effects, such as 
oedema, bony erosions, pain, muscular spasm, etc. 

How do you treat aneurism ? 

1. Medical treatment. Absolute rest. Very restricted diet. 
Iodide of potassium. 

2. Surgical treatment. (1. ) Pressure. May be direct, upon the 
aneurismal sac, or indirect, upon the artery above or below. It 
may be digital, instrumental, or applied by an Esmarch's band- 
age. It may be so applied as to merely slow the blood-current 
producing laminated clots, or may completely stop the circulation 
(rapid pressure). (2.) Flexion. Usually combined with pres- 
sure. (3.) Ligation. The thread may be applied to the ar- 
tery, 1, above the aneurism, and at some distance from it 
(Hunter's operation), 2, just above the aneurism (Anel's opera* 
tion), 3, both above and below the aneurism (operation of 
Antyllus, or old operation), 4, just below the aneurism (Brasdor's 
operation), 5, to one or more of the main branches below the 
aneurism (Wardrop's operation). (4.) Manipulation. (5.) Gal- 
vano-puncture. (6. ) Injections. (7. ) Introduction of foreign bodies. 

Describe the application of digital pressure to the cure of aneu- 
rism. 

This, if it can be applied on the proximal side of the artery at 
some distance from the sac, is superior to other methods of pres- 
sure, since it is less painful, it is less liable to injure the soft 
parts, it does not obstruct venous circulation. This method can 
be combined with flexion and instrumental compression. Kelays 
of assistants are necessary for its proper application. The pres- 
sure is made with the thumbs, the artery being controlled by the 
next assistant before the one pressing is relieved. A hand should 
be kept constantly on the sac to see that pulsation is prevented. 

This method is not applicable to very large aneurisms accom- 
panied by much oedema from venous obstruction, or aneurisms 



ANEURISM. 249 

occurring in habitual drunkards or those of irritable disposi- 
tion. 

Describe Hunter's method of ligation. 

The ligature is applied so high above the artery that a double 
collateral circulation is established, one around the thread, the 
other around the aneurism. The cure is effected by diminish- 
ing the circulation, and favoring the deposition of laminated clots 
in the aneurisraal sac ; these organize much more readily than 
the currant-jelly clots. 

When the ligature is applied, pulsation can no longer be felt 
in the aneurism ; after awhile a slight pulse is again perceptible ; 
as the sac becomes occluded, this pulsation becomes more feeble, 
till it finally ceases permanently. After operation, the limb 
should be swathed in cotton, elevated, and kept warm. 

What are the dangers of ligation ? 

Gangrene, secondary hemorrhage, suppuration and sloughing, 
recurrent pulsations. 

What are the objections to ligation close to the aneurismal sac ? 

The artery is probably not healthy. The circulation is abso- 
lutely stopped, hence there is clotting in mass. The anatomi- 
cal relations of the vessel are frequently altered by the tumor, 
making the operation difficult. The aneurismal sac is liable to 
injur}' during the operation. 

How do you treat traumatic aneurisms ? 
Turn out the clots, and ligate above and below. 

What knot would you use to ligate for aneurism ? 

The stay knot of Ballance and Edmunds, a double ligature 
of floss silk being used. 



250 ESSENTIALS OF SURGERY 



DISEASES OF THE LYMPHATICS. 

Describe lymphangitis. 

Definition. Inflammation of lymphatic vessels. 

Causes. Septic absorption from a wound, or simple trauma- 
tism. 

Symptoms. Irregularly placed erythematous patches, and red 
lines running to the nearest lymphatic glands, which are en- 
larged and tender. Chill followed by fever. 

Treatment. Cleanse wounds and render aseptic. Promptly 
evacuate pus. Elevate and apply hot antiseptic fomentations. 
On subsidence of acute symptoms, apply belladonna and mer- 
cury ointment, together with pressure. Clear the bowels, give 
diaphoretics and diuretics. 

Differential diagnosis. From phlebitis, by absence of knotted, 
corded feeling, and dusky redness in the course of veins; by the 
presence of glandular involvement. 

Describe lymphadenitis. 

Definition. Inflammation of lymphatic glands. May be acute 
or chronic. 

Acute lymphadenitis is usually secondary to inflammation of 
soft parts. The symptoms are those of inflammation or abscess. 
The treatment consists in cleansing the source of trouble, the 
use of hot applications, prompt incision for pus, pressure, and 
applications of mercury and belladonna. 

Chronic lymphadenitis. Common in strumous children, arises 
from slight irritation or without obvious cause. Glands of the 
neck frequently affected. Characterized by slow, painless, en- 
largements, which discharge curdy pus on breaking down, and 
leave indolent, undermined ulcers. 

Treatment. Counter-irritation by iodine till signs of softening, 
then incise, curette, and dress antiseptically. Nourishing diet, 
fresh air, cod-liver oil, iodide of iron. 



EFFECTS OF COLD 



251 



EFFECTS OF COLD. 



How may death occur from cold ? 

From cerebral anazmia, caused by sudden and progressive 
chilling. From cerebral congestion, due to slow and continuous 
chilling. From embolism, due to sudden reheating. 

Describe the local effects of cold. 

Pernio or chilblain. Caused by sudden alterations in tempera- 
ture. Characterized by swelling, congestion, vesication, and 
intense itching and burning. Frequent recurrence from slight 
causes. 

Treatment. Kestore circulation gradually by friction with 
snow, by the use of cold water. Apply a one per cent, solution 
of nitrate of silver, and wrap in raw cotton. 

Frost-bite. Characterized by actual congelation of the part, 
which is brittle and of a tallowy whiteness ; subsequently in- 
flammation of a high grade appears, and may be followed by 
gangrene. 

Treatment. Moderate the severity of reaction by rubbing with 
snow, continued cold irrigation, massage. If mortification ap- 
pears, continue the use of cold as long as this process is inclined 
to spread. Amputate when the line of separation is formed. 



252 ESSENTIALS QF SURGERY 



FOREIGN BODY IN THE AIR-PASSAGES. 

At what portions of the air-passages do foreign bodies become 
impacted ? 

Commonly in the larynx, or the right bronchus. 

What are the symptoms of foreign body in the air-passages? 

If impacted in the larynx. Asphyxia from spasm and obstruc- 
tion ; this may cause immediate death, or, the first spasm passing 
away, may be succeeded by an exhausting cough, a blood-stained 
mucous expectoration, and recurring spasmodic attacks. 

If loose in the trachea. Recurring and violent attacks of spas- 
modic asphyxia from impact of the body against the rima 
glottidis, free secretion of a frothy mucus from the air-passages. 

If impacted in a bronchus. Pain and whistling rales at the 
seat of lodgment, absence of respiratory sounds in the lung, 
abscess. 

Treatment. If dyspnoea urgent, instant tracheotomy. If the 
foreign body is lodged in the larynx, an effort should be made to 
remove it by laryngeal forceps ; failing in this perform laryn- 
gotomy and thyrotomy if necessary ; let the patient wear a 
tracheal tube for twenty-four hours. If the foreign body is loose 
in the trachea, immediately tracheotomize, draw the wound open, 
invert the patient, and instruct him to cough. If the foreign 
body is lodged in a bronchus, endeavor to extract by means of 
wire or an instrument, passed through a tracheal opening. 

What is bronchotomy ? 

Laryngotomy and tracheotomy, with their modifications. 1. 
Thyrotomy, opening through the thyroid cartilages. 2. Laryn- 
gotomy, opening through the crico-thyroid membrane. 3. 
Laryngo-tracheotomy, opening through crico-thyroid mem- 
brane, cricoid cartilage, and upper rings of the trachea. 4. 
Tracheotomy, opening through the rings of the trachea. 

Under what circumstances is bronchotomy required? 

Acute laryngitis, or oedema glottidis. Spasm. Emphysema. 
Foreign bodies in the air-passages, or gullet. Croup. Diph- 
theria. Polypi. 



FOREIGN BODY IN THE AIR- PASS AG ES . 253 

What structures lie in the middle line of the neck ? 

Thyrohyoid membrane, thyroid cartilage, crico-thyroid mem- 
brane and arteries, cricoid cartilage, two or three tracheal rings, 
isthmus of the thyroid, trachea. 

Describe laryngotomy. 

Longitudinal skin incision, an inch-and-a-half long, is made 
over the thyroid cartilage, thyro-cricoid membrane, and cricoid 
cartilage ; the crico-thyroid membrane is opened by a transverse 
cut. 

Describe tracheotomy. 

In the high operation the opening is made above the isthmus 
of the thyroid ; in the low operation it is made below. 

Incision for high operation, two and a half inches long, begin- 
ning at the upper border of the cricoid cartilage. Divide skin, 
superficial fascia, sterno-hyoid and sterno-thyroid inter-muscu- 
lar fascia, and loose cellular tissue. Avoid anterior jugular veins 
and their communicating branch, inferior thyroid vein, and mid- 
dle thyroid artery, if present. Draw the trachea forward with 
a tenaculum, incise, cutting from below upward, and pass in the 
tracheal tube. Check all bleeding before opening the larynx, 
except when death from asphyxia is imminent, or when the 
bleeding is due to intense venous engorgement. 

After-treatment should be conducted in a warm, moist atmo- 
sphere ; the opening of the tracheal tube should be protected by 
moist gauze, and a physician or nurse should be constantly 
present to clean the inner tube when it becomes filled. When 
the breathing becomes hissing, and the epigastrium and intercos- 
tal spaces are sucked in during inspiration, the tube is danger- 
ously clogged. Bronchitis, pneumonia, or the disease which 
necessitates the operation, are the common causes of death after 
this operation. 



Affections of the (Esophagus. 

Where are the narrowest portions of the oesophagus ? 

At its commencement (the lower border of the cricoid carti- 
lage), and as it passes through the diaphragm. 



254 ESSENTIALS OF SURGERY. 

What are the symptoms of foreign body in the oesophagus ? 

Pain, difficulty in swallowing, and frequently, asphyxia from 
spasm or direct pressure. 

How do you treat foreign body in the (esophagus? 

If suffocation threatens, tracheotomize at once. Under other 
circumstances, endeavor to extract by forceps, or by the swivel 
or horsehair probang. If the body is of such a nature that 
it can be digested, or passed by the bowel, push it into the 
stomach. If the body is irregular and tightly lodged, perforin 
cesophagotomy. 

Describe stricture of the oesophagus. 

1. Spasmodic. Occurs in young hysterical women. Gives 
trouble only at times. Under ether, a bougie is passed without 
difficulty. 

2. Fibrous. Due to contractions following traumatism or 
syphilis. 

3. Malignant. Generally epitheliomatous. Occurs opposite 
cricoid cartilage, tracheal bifurcation, or at cardiac end of stom- 
ach. 

Symptoms of fibrous or malignant stricture are, increasing dif- 
ficulty in swallowing, first solids then liquids giving trouble. A 
feeling of obstruction referred to the top of the sternum, regurgi- 
tation of swallowed food, progressive wasting. Finally the di- 
agnosis is made by passage of bougies (after excluding aneurism, 
which has been burst by this procedure). 

Treatment. Dilatation or internal cesophagotomy for fibrous 
strictures. GEsophagotomy (establishment of a fistulous open- 
ing into the oesophagus), or gastrostomy for malignant strictures. 

Abbe's operation for cicatricial stenosis consists in doing a 
gastrotomy and an cesophagotomy, passing a string in through 
the stomach and out through the wound in the oesophagus, and 
using the string as a saw to cut the constriction. 



SURGICAL AFFECTIONS OF THE BREAST. 255 



SURGICAL AFFECTIONS OF THE BREAST. 

In what situation may abscesses of the breast occur ? 

Supra-mammary, superficial to the gland. Tntra-mammary, 
within the gland. Post-mammary, behind the gland. 

Give the treatment of mammary abscess. 

Early and free incision in a direction radiating from the nip- 
ple, drainage, and pressure by means of bandages or concentric 
strapping. 

What is Paget's disease of the nipple? 

An inflammatory condition of the nipple and areola which 
frequently precedes the development of cancer. 

What tumors are most frequently found in the breast? 

Scirrhus, fibroma, sarcoma. 

Give the differential diagnosis between scirrhus and non-malig- 
nant breast tumors. 

Scirrhus. Non-malignant tumors. 

Occurs after the fortieth year. Occurs before the fortieth year. 

Very hard, nodulated, shortly be- Nodulated, moderately hard, elas- 
comes fixed. tic, movable. 

Skin infiltrated and adherent. Skin free and movable. 

Nipple retracted, superficial veins None of these signs present, 
dilated, lancinating pain. 

Lymphatic involvement, rapid 
grcvrth, quick recurrence, cachexia. 



256 ESSENTIALS OF SURGERY 



CLUB-FOOT. 

Describe the common forms of club-foot. 

1. Talipes varus. The sole of the foot looks inward. This is 
the commonest congenital form (usually equino-varus) ; when 
it affects both feet it is frequently associated with spina bifida. 
Cause. Contraction of tibialis anticus and posticus, muscles of 
the calf, and the plantar fascia. Treatment. Division of all re- 
sisting tissues. 

2. Talipes equinus. The heel is raised. Cause. Contraction 
of gastrocnemius and soleus, or paralysis of the opposing mus- 
cles. Treatment. Division of tendo Achillis. 

3. Talipes valgus. The foot is everted. Caused by long-con- 
tinued standing, or anything tending to obliterate the plantar 
arch ; the peronei muscles subsequently contract. Treatment. 
Friction, support to the arch of the foot, and section of peronei 
tendons, if necessary. 

4. Talipes calcaneus. The toes are raised by the extensors. 
Causes. Contraction of the anterior muscles, or paralysis of those 
of the calf. Treatment. Section of the tibialis anticus, extensor 
longus pollicis, extensor longus digitorum, peroneus tertius. 

There may be a combination of distortions, constituting equino- 
varus, calcaneo-v^rus, etc. 



HARE-LIP AND CLEFT PALATE. 



257 



HARE-LIP AND CLEFT PALATE. 



Fig. 58. 




What is hare-lip ? 

A congenital deformity, characterized by a fissure or fissures on 
the upper lip, due to arrested development. Hare-lip is single 
when one side is involved, double 
when it appears on both sides. It 
is frequently associated with cleft 
palate. 

The treatment consists in closing 
the fissure, by freshening the edges 
and bringing them together with 
hare-lip pins, or by performing a 
plastic operation, sacrificing none of 
the tissues. 

What is cleft palate ? 

A congenital cleft in the median 
line of the palate ; it may be con- 
fined to the uvula, the soft palate, 
or involve the entire roof of the 
mouth. 

Staphylorrhaphy indicates the operation for the closure by 
suture of the soft palate. The method of closing the fissure by 
a transparent flap from the pharynx is termed staphyloplasty. 
The flap operation for the closure of clefts in the hard palate is 
termed uranoplasty. 




Operation for hare-lip. 



17 



258 ESSENTIALS OF SURGERY. 

DISEASES OF BURSJE AND TENDONS. 

Bursitis. 

Describe bursitis. 

Bursitis is characterized by pain, fever, and the rapid develop- 
ment of a fluctuating swelling. The bursa patellae is commonly 
involved, constituting, in the chronic form, " housemaid's knee." 
This swelling is diagnosed from intra-articular effusions by the 
fact that it is above the bone. Inflammation of the bursa over 
the olecranon constitutes u miner's elbow. " " Weaver's bottom" 
is an inflammation of the bursa over the tuber ischii. 

Treatment. Leeches, evaporating lotions, counter-irritation, 
and splinting. If suppuration, free incision. 

How do you treat dropsy of a bursa? 

This condition is usually due to subacute inflammation, or 
long-continued pressure. It may, at times, be resolved by 
counter-irritants, more commonly it will require incision and 
scraping. 

What is a bunion ? 

A bursal enlargement occurring in the foot. It is usually 
placed at the side of the metatarsal joint of the great toe. 

What is tenosynovitis ? 

Inflammation of tendons and their sheaths ; due to traumatism, 
gout, or rheumatism. CJiaracterized by a puffy swelling along the 
tendon, and fine crackling crepitation. Treated by iodine or 
blisters. 

What is a ganglion ? 

A cyst formed in connection with the sheath of a tendon. The 
simple ganglion is developed on the synovial sheath. The com- 
pound ganglion consists of a dilatation which commonly involves 
the sheaths of several tendons. Ganglion occurs upon the ex- 
tensor tendons at the back of the wrist, and in front of the ankle. 
It can be felt as a round, tense, fluctuating, freely movable 



DISEASES OF BURSil AND TENDONS. 259 

tumor, sometimes giving considerable pain on motion, and 
always causing some loss of power. 

Treatment. Subcutaneous rupture, either by force or by the 
tenotome. Incision and curetting. 

What is paronychia ? 

Synonyms. Whitlow. Felon. Panaris. 

Definition. An acute septic inflammation, involving the 
sheath of the tendon, the tissues superficial to it, or the peri- 
osteum, or all these structures. Always due to a septic wound. 
Characterized by intense pain, rapid disorganization, and ten- 
dency to spread along the course of the tendon. Treated by 
early, free incision, scraping, and thorough disinfection. 



Onychia. 

What is onychia ? 

Inflammation of the matrix of the nails. 

May be simple onychia or "run around," due to injury, and 
attended by suppuration and loosening of the nail. Treated by 
wet boric acid dressing. 

Malignant onychia, due to injury and profound constitutional 
depression ; characterized by fungous ulcerations, showing no 
tendency to heal. Treated by trimming the nail, and applying 
powdered nitrate of lead to the granulations. 

What is ingrowing toe nail ? 

An ulceration, caused by tight shoes pressing the soft part of 
the toe against the edge of the toe nail. Kemedied by wearing 
loose shoes, packing absorbent cotton and iodoform between the 
soft parts and the nail, or by avulsing the nail. 



260 ESSENTIALS OF SURGERY. 



ANAESTHETICS. 

What substances are used to produce anaesthesia? 

General anaesthesia is induced by nitrous oxide, chloroform, 
or ether. Local anaesthesia is induced by cocaine or freezing. 

Which is the safest general anaesthetic ? 

Nitrous oxide for brief operations (one minute), ether for ma- 
nipulations requiring more time. 

What is the danger in chloroform inhalation ? 

Cardiac syncope. It may attack the robust and apparently 
healthy. Particularly liable to occur when operations about the 
anus are begun before complete anaesthesia. 

How do you prepare patients for the administration of anaes- 
thetics ? 
Give no food for six hours before the time of administration. 
Examine the urine, and carefully auscult the lungs and heart. 
Half an hour before the administration of the anaesthetic give to 
anaemic and nervous patients a full dose of whiskey or wine. See 
that there are no artificial teeth or foreign bodies in the mouth. 
Loosen the clothing about the neck and chest. In drunkards the 
anaesthetic should be preceded by a quarter of a grain of morphia. 

How do you administer ether ? 

Use a folded towel, or one of the many inhalers. The recum- 
bent position should be enforced. Protect the eyes by a folded 
towel. Let the vapor be very dilute for the first few inhalations, 
increasing the strength as the patient loses consciousness. Per- 
sistent cough is most quickly overcome by pushing the ether. 
Watch the respiration and pulse. When the pulse is slow and 
full, the respirations deep and snoring, the reflex irritability 
abolished, and the patient totally relaxed, the anaesthesia is car- 
ried to the limit of safety. 

What accidents may occur during the administration of ether? 

In the first stage there may be respiratory forgetfulness, or a 
Cessation of breathing efforts, tbQugh consciousness is still pre- 



ANESTHETICS. 261 

served. Corrected by sudden pressure or a dash of ether over 
the epigastrium. 

In the third stage mucus may collect in the throat to such an 
extent as to embarrass respiration ; it should be mopped out by 
sponges tied to sticks. If there is vomiting, the head should be 
turned to the side. If the air does not enter the lungs freely, the 
lower jaw should be pushed forward by the fingers placed be- 
neath the ramus. 

There may be threatened asphyxia, from excess of ether, drop- 
ping back of the tongue, or closure of the glottis. Denoted by 
irregular pulse, laryngeal stertor, blue surface, absence of respi- 
ratory movements. Immediately push the angles of the jaw 
forward and extend the head, practise artificial respiration, 
clash ether over the epigastrium, raise the foot of the bed or table, 
and intermittently apply the electric brush to the epigastrium, 
the other pole of the battery being placed over the sternum. 
Tracheotomy may be performed and the lungs inflated directly. 

What precautions are taken during the administration of ether ? 

Lights, if near, should always be held above the level of the 
ether. The ansesthetizer should devote his entire attention to 
the patient. The respiration, the pulse, the color of the skin, 
and the pupil should be carefully noted. A third person should 
always be present when women are etherized. 

What are the indications for allowing the patient more air ? 

A feeble frequent pulse. Lividity of the surface. Laryn- 
geal stertor. Pallor and tonic spasm. A pupil fixed in dilata- 
tion (always a sign of great danger). Paralysis of the diaphragm, 
denoted by purely thoracic breathing, with sucking in of the 
belly walls with each inspiration. 

Under what circumstances is chloroform preferred to ether ? 

When there is emphysema of the lungs, bronchitis, kidney dis- 
ease, or vascular degeneration. In infants. In operations about 
the mouth, when the cautery may be required. 

How do you administer chloroform ? 

The vapor must not be stronger than four parts to the hundred 
of air. Pour a few drops upon a piece of lint or a towel and 



262 ESSENTIALS OF SURGERY. 

hold it a short distance from the mouth and nose. Watch the 
pulse most carefully. 

How do you treat syncope in chloroform narcosis ? 

Push the lower jaw far forward, and extend the head. Baise 
the foot of the table high up. Dash cold water over the face 
and chest. Begin artificial respiration immediately. 

Should you give ether in shock ? 

As ether directly lowers the temperature, it should not be 
given when shock is marked. After restoration of temperature 
and the free administration of whiskey and opium, a minimum 
quantity will be required, and may be cautiously administered. 



LIGATION OF ARTERIES. 263 

y LIGATION OF ARTERIES. 

Under what circumstances is an artery ligated in its conti- 
nuity ? 

1. In the treatment of aneurism. 

2. In the checking of bleeding, under certain circumstances. 

3. In the treatment of inflammation. 

What instruments are required for the operation ? 

Scalpel, dissecting and artery forceps, blunt hooks, retractors, 
grooved director, aneurism needle, ligature, needles, and dres- 
sings. All should be arranged in trays and covered with car- 
bolic solution 1:20 ; which is diluted up to 1:40, when the ope- 
ration is begun. 

Describe the ligatures and dressings. 

Ligature of antiseptic, prepared cat-gut. After operation, the 
wound, if small, is closed without drainage ; if large, it is drained 
by means of rubber tubes, horsehair, or strands of cat-gut. Its 
edges are closely approximated, and the whole covered in by a 
careful antiseptic dressing. 

What precautions are taken in performing the operation? 

1. Begin and end the superficial cut with the knife-blade ver- 
tical to the surface, thus avoiding "heeling." 

2. Divide the deep fascia to the full extent of the superficial 
cut. Open the sheath by cutting toward the dissecting forceps, in 
which a portion of its periphery is pinched up. The incision is 
subsequently enlarged by the director. Avoid forcible tearing 
or wide separation of the artery from its sheath. Pass the an- 
eurism needle from the side where the most important and vul- 
nerable structures are placed. Before tying, compress the artery 
and feel for pulsation below, to be sure that the circulation is 
controlled. 

In securing the ligature, make more tension upon the first 
than upon the second knot. 

What complications may arise in the after-treatment of liga- 
tion? 
Gangrene, hemorrhage, return of pulsation in aneurism. 



264 ESSENTIALS OF SURGERY. 

Describe the after-treatment of ligation. 

Elevate the limb and surround it with a thick layer of wool. 
Keep at absolute rest. Light, nutritious diet. Strict quiet, 
both mental and physical. 

Describe the triangles of the neck. 

Anterior triangle. In front, the middle line. Behind, the 
sterno-cleido-mastoid. Above, the base of the lower jaw, and 
a line from its angle to the mastoid process. Apex, at the 
sternum. Subdivided into three smaller triangles by the digas- 
tric above, and the anterior belly of the omo-hyoid below, named 
from below up, the inferior carotid, the superior carotid, and 
the submaxillary. 

Inferior carotid triangle. In front, middle line. Behind, 
sterno-raastoid. Above, anterior belly of omo-hyoid. 

Superior carotid triangle. Behind, sterno-mastoid. Below, an- 
terior belly of omo-hyoid. Above, posterior belly of digastric. 

Submaxillary triangle. Above, body of jaw, parotid gland, 
and mastoid process. Below, posterior belly of digastric, and 
stylo-hyoid. In front, median line. 

Posterior triangle. In front, sterno-mastoid. Behind, trape- 
zius. Below, clavicle. Apex, at occiput. Divided by the poste- 
rior belly of the omo-hyoid into an upper or occipital, and a 
lower or subclavian triangle. 

Occipital triangle. In front, sterno-mastoid. Behind, trape- 
zius. Below, omo-hyoid. 

Subclavian triangle. Above, posterior belly of omo-hyoid. Be- 
low clavicle. In front, sterno-mastoid. 

Common carotid. Origin— right, from the innominate, behind 
the sterno-clavicular articulation ; left, from the arch of the 
aorta, more deeply placed. Extent — from behind the sterno- 
clavicular articulation to the upper margin of the thyroid carti- 
lage. The carotid artery lies in the same sheath with the 
internal jugular vein and the pneumogastric nerve, each of these 
structures being separated from the other by fibrous septa, and 
having a distinct compartment. The sheath rests upon the lon- 
gus colli, and, in the upper part of its course, the rectus capitis 
anticus muscles, and is crossed at the level of the cricoid carti- 
lage by the omo-hyoid muscle. 



LIGATION OF ARTERIES. 



265 



Line. From the sternoclavicular articulation to a point mid- 
way between the angle of the jaw and the mastoid process. 
Superficial guide — anterior border of sterno-cleido-mastoid. 

Belations. Anterior. Skin, superficial fascia, platysma, deep 
fascia, sterno-hyoid, sterno-thyroid, sterno-mastoid muscles ; su- 

Fig. 59. 




Lines of incision for carotid, facial, lingual, subclavian, and axillary arteries. 

perior and middle thyroid, and anterior jugular veins ; descen- 
dens noni and communicans noni nerves. Posterior. — Longus 
colli and rectus capitis anticus muscles ; sympathetic, recurrent 
laryngeal nerves ; inferior thyroid artery. Internal. — Trachea, 
oesophagus, larynx, pharynx, recurrent laryngeal nerve, and 
inferior thyroid artery. External. — Internal jugular vein, infe- 
rior thyroid artery. On the left side the internal jugular vein 
is somewhat anterior to the artery. 

Collateral circulation. Inferior with superior thyroids, ascend- 
ing branch of transversalis colli with princeps cervicis, terminal 
branches of internal and external carotids on the two sides. 

Operation, above the omo-hyoid. Patient supine with a pillow 
under the shoulders and neck, head extended, face turned 



266 ESSENTIALS OF StTRGERY. 

towards sound side. Incision, three inches, along the anterior 
border of the sterno-cleido-nmstoid muscle, and with its centre 
on a level with the cricoid cartilage. Divide skin, superficial 
fascia, platysma, deep fascia. With retractors draw aside the 
sterno-mastoid. Expose the omo-hyoid by cutting through a 
dense fascia covering it and the sheath of the vessels, carefully 
avoiding the venous plexus formed by the superior thyroid with 
its communications from the lingual, facial, anterior and ex- 
ternal jugular. The sheath of the artery is found bisecting the 
angle made by the anterior belly of the omo-hyoid and the 
anterior border of the sterno-mastoid. Open the inner compart- 
ment of the sheath, avoiding descendens and communicans noni 
nerves, and pass the ligature from without inward. 

External carotid. A branch of the common carotid, given 
off at upper border of thyroid cartilage. It extends from the 
superior border of thyroid cartilage, to neck of condyle of lower 
jaw. 

Chief relations. Anterior. Hypoglossal nerve, lingual and 
facial veins, digastric muscle. Posterior. Superior laryngeal 
and glossopharyngeal nerves. Internal. Hyoid bone and 
pharynx. External. Internal carotid artery and internal jugu- 
lar vein. 

Collateral circulation. Lingual, superior thyroid, occipital, 
and the same of the opposite side. 

Operation. Incision midway between angle of jaw and ante- 
rior border of sterno-cleido-mastoid muscle, carried down three- 
eighths of an inch in front of the latter to one-half inch below 
upper border of thyroid cartilage. Divide skin, superficial fascia, 
and platysma at once. Slit up the deep fascia spreading from 
the anterior border of the sterno-cleido-mastoid, avoiding the 
external jugular, temporal, and facial veins. By blunt dissection 
the parotid gland and the posterior belly of the digastric are ex- 
posed ; the latter is drawn upward with blunt hooks, when the 
external carotid is found, crossed by the hypoglossal nerve, with 
the superior laryngeal nerve lying beneath. 

Pass the needle from without inward. 

Lingual. Is given off from the external caiotid between the 
superior thyroid and facial. 



LIGATION OF ARTERIES. 267 

Iu the first part of its course, from its origin to the posterior 
border of the hyoglossus, it passes obliquely up and in to the 
great cornu of the hyoid bone, and is covered simply by skin, 
fasciae, platysma, and veins, resting on the middle constrictor. 
In the second part of its course, beneath the hyoglossus muscle, 
it runs parallel with the great horn of the hyoid, then ascends to 
the tongue. It is crossed here by the posterior belly of the 
digastric and the stylo-hyoid muscles, and is covered by the 
hyoglossus muscle. 

Cfiief relations. Anterior. Hyoglossus muscle. Posterior. 
Middle constriction of pharynx, and genio-hyoglossus muscle. 
Above. Hypoglossal nerve. Below. Tendon of digastric, and 
great horn of hyoid bone. 

Point of election. Second part of artery, lying beneath hyo- 
glossus. 

Operation. Incision three inches ; begin a little below and 
internal to the symphysis menti, convex downward to the great 
horn of the hyoid, and outward to the inner border of the sterno- 
mastoid. The three outer layers being divided the submaxillary 
gland is reached, lying in the deep fascia ; the latter is divided 
and the gland turned up exposing the tendon of the digastric, 
and the hypoglossal nerve above ; the nerve is dissected up and 
retracted exposing the hyoglossus muscle, which, when divided 
upon a director, enables the operator to pass the ligature about 
the artery from above downwards. Superficial guide, great horn 
of hyoid. Deep guide, nerve and tendon. 

Facial arises from external carotid, a little above the lingual, 
passes beneath the posterior belly of the digastric and stylo- 
hyoid muscles and hypoglossal nerve, winds through a groove in 
the posterior and upper border of the submaxillary gland, and 
crosses the lower jaw in a slight depression just in front of the 
insertion of the masseter muscle. Here is the point of election ; 
the artery is covered at this point by skin fascia and platysma. 

Operation. Incision one inch, just on the jaw, along the 
anterior border of the masseter muscle ; vein lies posteriorly. 
Pass the thread from behind forward. Guides. Anterior edge of 
masseter muscle, and groove in the submaxillary bone. 



268 ESSENTIALS OF SURGERY. 

Occipital arises from the external carotid opposite the facial, 
and passes backwards under the posterior belly of the digastric, 
the stylo-hyoid, and the lower part of the parotid gland, across 
the internal carotid artery, internal jugular vein, and the pneu- 
mogastric and spinal accessory nerves. The hypoglossal nerve 
hooks around it beneath the gland. The artery ascends the 
neck to the level of the transverse process of the atlas, passes 
through a groove on the mastoid process of the temporal bone, 
beneath the sterno-mastoid, splenius, digastric, and trachleo- 
mastoid, pierces the insertion of the splenius, and becomes super- 
ficial. 

Operation. Point of election. Occipital portion. Incision from 
the apex of the mastoid process backward and very little upward 
for two inches. Divide skin, superficial fascia, deep fascia, and 
outer border of the sterno-mastoid, the splenius, the complexus. 
Guides. Transverse process of the atlas, and the mastoid process ; 
the artery is found between the two, and can be traced outward 
to a more superficial position. Isolate from the occipital vein, 
and ligate. 

Temporal. A terminal of the external carotid. It lies in the 
space between the condyle of jaw and external auditory meatus. 

Line. Directly upward, between the condyle of jaw and the 
cartilage of the ear. 

Chief relations. Anterior. Branches of facial and auriculotem- 
poral nerves. Posterior. Vein, and facial and auriculo-temporal 
nerves. As it crosses the root of the zygoma, the artery is cov- 
ered by a dense fascia derived from the parotid gland, this 
should not be opened. 

Operation. Incision vertical, one inch long, between the car- 
tilage of the ear and the condyle of the jaw. Skin, superficial 
fascia, and some fibres of the attrahens aurem are divided, 
artery freed, and thread passed from behind forward. 

Subclavian. On the right side from the innominate. On the 
left side from the arch of the aorta. Three portions — 

1. From its origin to inner border of scalenus anticus. This 
portion gives off the thyroid axis, the vertebral, and the internal 
mammary arteries. 



LIGATION OF ARTERIES. 269 

2. Behind the scalenus anticus. Gives off superior intercostal 
artery on the right side. 

3. Outer edge of scalenus anticus to lower border of first rib. 
Point of election is the outer third. 

Relations of the outer third. Posterior. Scalenus medius. Above 
and external. Brachial plexus. Anterior and below. Subclavian 
vein. Internal. Edge of scalenus anticus. Structures lying in 
front. Skin, superficial fascia, platysma, deep fascia, a plexus 
of veins formed by the external jugular, suprascapular, and 
transversalis colli ; clavicle and subclavius muscle ; suprascapu- 
lar artery. 

Operation. Position of patient, recumbent, shoulder supported 
on pillows, head back, face toward sound side, arm of the affected 
side depressed as much as possible. Superficial guide, most promi- 
nent part of clavicle. Deep guides, brachial plexus above and 
behind, outer edge of scalenus anticus muscle, and tubercle of 
first rib internal. Incision. The skin is drawn down from the 
neck over the clavicle, and a three-inch incision made upon the 
bone, from the external border of the sterno-mastoid muscle out- 
wards. On releasing the skin this wound lies somewhat above 
the clavicle. Secure or push aside the external jugular vein, 
open the deep fascia, feel for the tubercle of the first rib and 
the outer border of the anterior scalene muscle ; free the artery 
by blunt dissection, and pass the thread from below. 

Collateral circulation. Suprascapular artery and posterior 
scapular, branch of the transversalis colli with the subscapular 
and circumflex. Internal mammary, superior intercostal, and 
aortic intercostals, with the long and short thoracics. 

First part of subclavian artery. Right side. In front. Skin, 
superficial fascia, platysma, and deep fascia. Three muscles, 
sterno-mastoid, sterno-hyoid, sterno-thyroid. Three veins, 
internal jugular, vertebral, anterior jugular. Three nerves, 
vagus, cardiac filaments of sympathetic, phrenic. Behind. 
Longus colli, and three nerves, sympathetic cardiac branches 
of vagus and recurrent laryngeal. Below. Pleura and recur- 
rent laryngeal. 

Left side. Longer, more deeply placed, ascends almost verti- 
cally to neck. In front. Pleura, lung, internal jugular and 



270 ESSENTIALS OF SURGERY. 

innominate veins, the same muscles and nerves as on the right 
side. Behind. (Esophagus, thoracic duct, and as on right side 
except the recurrent laryngeal. Inner side. (Esophagus, trachea, 
thoracic duct. Outer side. Pleura and lung. 

Second, part of the subclavian. Rests between the anterior and 
middle scalene muscles, with brachial plexus above; phrenic 
nerve, transversalis colli and suprascapular arteries in front; 
and pleura below. 

Internal mammary. Arises from the first portion of the sub- 
clavian and passes down behind costal cartilages to sixth inter- 
space. Line of incision is vertical, two and one-quarter inches 
long, beginning at lower border of clavicle one-quarter of an inch 
external to margin of sternum ; or the incision may be trans- 
verse. The point of election is in the first three intercostal 
spaces. 

Chief relations. Anterior. Costal cartilages and internal 
intercostal muscles. Posterior. Pleura. As it is about to enter 
the chest it is crossed by the phrenic nerve. 

Axillary. Continuation of the subclavian. Extends from the 
lower border of the first rib to the lower border of the insertion 
of the teres major. 

Course. With abducted arm, from the middle of the clavicle to 
the inner border of the coraco-brachialis muscle. Three portions — 

1. Lower border of first rib to upper border of pectoralis 
minor. Branches. Superior thoracic, acromio-thoracic ; the latter 
runs along the upper border of the pectoralis minor. 

2. Behind pectoralis minor. Branches. Long thoracic, at the 
lower border of the pectoralis minor, alar thoracic. 

3. From lower border of pectoralis minor to insertion of latis- 
simus dorsi and teres major. Branches, subscapular running in 
the posterior axillary fold, posterior circumflex, anterior circum- 
flex. 

Points of election. First and third portions, particularly the 
last. 

Operation. First part. Patient supine, arm carried from the 
side. Incision three inches, commencing one-half inch from the 
sterno-clavicular articulation, extending outward along the line 



LIGATION OF ARTERIES. 271 

between the sternal and clavicular portions of pectoralis major. 
Work upward and backward between the two portions of 
the pectoral muscle till a dense fascia, the costo-coracoid, is 
reached ; depress the shoulder and tear the fascia with the 
director, when the axillary vein is found ; behind it is the artery, 
and still deeper the brachial plexus. Pass the ligature from below. 
Guides. The brachial plexus behind and above. Subclavian vein, 
below and in front. Inner border of pectoralis minor, externally. 

Third portion. Arm abducted and supinated. Incision three 
inches long, in the hollow of the armpit, along aline passing from 
the junction of the anterior and middle third of the axilla to the 
middle of the bend of the elbow. Divide skin, superficial and 
deep fascias ; relax by bending the elbow, displace the median 
nerve to the outer side, the axillary vein with the ulnar and 
internal cutaneous nerves to the inner side. Open the sheath, 
and pass the thread from the inner side. 

Relations. In front. Skin and fascia only at lower part of its 
course. At the upper part, pectoralis major, internal cutane- 
ous nerve, inner head of median. Behind. Subscapulars, 
tendon of latissimus dorsi and teres major, musculo-spiral and 
circumflex nerves. Outer side. Coraco-brachialis, median nerves, 
musculo-cutaneous nerve. Inner side. Ulnar nerve, nerve of 
"VYrisburg, axillary vein. Guides. Superficial, the coraco- 
brachialis. Deep, the branches of the brachial plexus. 

Collateral circulation. Ligation of first part. Acromio- thoracic 
and superior thoracic with subscapular and circumflex. Long 
thoracic with intercostals and internal mammary. 

Ligation of third part. Posterior circumflex and subscapular 
with superior profunda ; anastomoses through muscular branches 
and through the bone. 

Brachial. Continuation of the axillary, from the lower bor- 
der of the teres major, along the inner and anterior aspect of arm 
to one-half inch below the bend of the elbow. Passes along the 
inner border of biceps and coraco-brachialis, which are its mus- 
cles of reference, or guides. 

Chief relations. Anterior. Skin and fascia ; at middle third 
median nerve ; at lower third, bicipital fascia with median basilic 



272 



ESSENTIALS OF SURGERY. 



Fig. 60. 



vein resting on it. Posterior. Long head of triceps, insertion of 
coraco-brachialis, brachialis anticus, musculo-spiral nerve, supe- 
rior profund artery. Inner side. Internal cutaneous and ulnar 
nerves, median nerve (below), basilic vein. Outer side. Median 
nerve (above), coraco-brachialis and biceps. The median nerve 
first to the outer side, passes in front, then to the inner side. 
Branches, 1 muscular, 2 superior profund, accompanying mus- 
culo-spinal nerve, 3 inferior profund, accompanying the ulnar 
nerve, 4 nutrient, 5 anastomotica magna. 

Operation. Arm extended and everted. Incision three inches, 
along the inner border of the biceps, or in the line of the artery 

(from the junction of the anterior 
and middle third of the axilla, to 
the middle of the bend of the el- 
bow). Avoid the median basilic 
vein if it lies in the superficial fas- 
cia at the seat of operation. 

At the bend of the elbow. Incision 
three inches. One-half inch inter- 
nal to the tendon of the biceps, the 
lower end lying over the neck of 
the radius. Divide skin, superfi- 
cial fascia, bicipital fascia, avoid- 
ing or tying the median basilic 
vein. The artery is exposed, lying 
upon the brachialis anticus, with 
the biceps tendon to its outer, the 
pronator radii teres muscle to its 
inner side. 

Collateral circulation. Circum- 
flex and subscapular with supe- 
rior profund ; profund with radial 
ulnar and interosseous recurrents. 




Relation of brachial artery to 
bicipital fascia, internal cutane- 
ous nerve, and median basilic vein 
it the bend of the elbow. 



Radial. A terminal of the 
brachial, passes from one-half inch 
below bend of elbow, along radial 
side of forearm to wrist, winds 
backwards around outer side of 



LIGATION OF ARTERIES. 273 

carpus beneath extensors of thumb, and enters palm of hand 
beneath the two heads of the first dorsal interosseous muscle. 
Line. From middle of bend of elbow to a point midway be- 
tween tendon of flexor carpi radialis, and styloid process of ra- 
dius. Guide. Inner border of supinator longus. 

Chief relations. Upper third. External, supinator longus mus- 
cle ; internal, pronator radii teres. Lower two-thirds. External, 
supinator longus ; internal, flexor carpi radialis. In the middle 
third the radial nerve is to the radial side of the artery. 

Operation. Division of skin and fascial only ; the artery is 
superficially placed in the muscular interspace. 

Ulnar. A terminal of the brachial. Commences one-half inch 
below middle of bend of elbow, crosses obliquely to ulnar side of 
arm, and continues along its ulnar border to the wrist. 

Line. From a point at junction of upper and middle thirds 
of forearm, and three-fourths of an inch external to ulnar border, 
to the radial border of pisiform bone. 

Chief relations. Below, flexor profundus digitorum ; external, 
flexor sublimis digitorum ; internal, flexor carpi ulnaris and ul- 
nar nerve. In the upper third of its course it lies beneath the 
superficial set of flexor muscles. In the lower two-thirds, in 
its muscular interspace beneath the superficial and deep fascia 
only. 

Operation. Pass the needle from within outwards. Guide — 
iexor carpi ulnaris. 

Palmar arches. Superficial. Direct continuation of the ulnar 
artery, convex downwards, completed by the superficialis volae 
of the radial, or the radialis indicis. Beneath it lie the digital 
arteries, nerves, and tendons of the flexor sublimis digitorum. 

Beep. The direct continuation of the radial, completed by the 
profunda branch of the ulnar ; it rests upon the palmar inter- 
ossei, and metacarpal bones near their carpal ends. It lies 
beneath the arteries, nerves, and tendons of both superficial and 
deep flexors. 

. Position of the arches. The superficial lies in a line drawn 
directly across the palm of the hand, from the angle of junction 
of skin covering the inner border of the thumb and the outer 
18 



274 ESSENTIALS OF SURGERY. 

border of the metacarpal bone of the index-finger. The deep 
arch lies a finger's breadth nearer the wrist. 

External iliac. A branch of the common iliac. Its course is 
represented by the lower two-thirds of a line drawn from three- 
fourths of an inch below and to the left side of the umbilicus, to 
a point midway between the anterior superior spinous process 
of the ilium and the symphysis pubis. Just above Poupart's liga- 
ment it gives off the deep epigastric, and the deep circumflex 
iliac. 

Chief relations. Anterior. Peritoneum, spermatic vessels, vas 
deferens, genital branch of genito-crural nerve, circumflex iliac 
vein. Posterior. Psoas magnus and, on the right side, the ex- 
ternal iliac vein. External. Psoas magnus. Internal. External 
iliac vein and vas deferens. 

Operation. Patient recumbent, shoulders raised, knees and 
thighs flexed. Incision. From one inch above anterior superior 
spinous process ilium, to external abdominal ring, parallel to 
Poupart's ligament. Pass the needle from within outwards, and 
avoid including the genital branch of the genito-crural nerve. 

Collateral circulation. Gluteal and obturator with external 
circumflex. Sciatic with superior perforating and circumflex 
branches of profunda. The deep circumflex iliac with the ilio- 
lumbar, the lower intercostals, and the lumbar branches of the 
aorta. Internal pudic with the external pudic and internal cir- 
cumflex. Mammary, inferior intercostals, and obturator with 
deep epigastric. 

Femoral. The direct continuation of the external iliac, and 
extends from the middle of Poupart's ligament to the opening 
in the adductor magnus. Its upper part is a little internal to the 
head of the femur ; its lower part lies to the inner side of the 
shaft of the bone. 

In Scarpa's triangle it is superficial. Below it is more deeply 
seated, and is in Hunter's canal. 

Line. From middle of Poupart's ligament to inner side of 
internal condyle. 



LIGATION OF ARTERIES 



275 



Branches. Superficial 
epigastric, superficial 
circumflex iliac, exter- 
nal pudic, profunda, 
femoris, anastomotica 
magna. 

Point of election. Apex 
of Scarpa's triangle. 

Belations. Behind. 
Psoas, pectineus, femo- 
ral vein, adductor lon- 
gus, adductor magnus. 
Inner side. Femoral 
vein, adductor longus, 
sartorius. Outer side. 
Psoas, vastus internus, 
femoral vein, internal 
cutaneous and long sa- 
phenous nerves. In 
front. Skin, superficial 
and deep fascia, internal 
cutaneous and long sa- 
phenous nerves, sarto- 
rius. The vein lies first 
to the inner side of the 
artery, at the apex of 
Scarpa's triangle be- 
hind, in Hunter's canal 
to the outer side. 

Operation. Point of 
election. Thigh flexed 
and rotated outward, 
knee bent. Incision four 
inches in the course of 
the vessel, its centre at 

Lines of incision for liga- 
tion of femoral, tibial, and 
dorsalis pedis arteries. 



Fig. 61. 







276 ESSENTIALS OF SURGERY. 

the apex of Scarpa's triangle. On dividing the deep fascia, draw 
the sartorius outwards. The sheath of the vessel is cleared, and 
the thread passed from the vein. 

Hunter's canal. Incision four inches exactly in the middle 
third of the thigh, and somewhat internal to the line of the 
artery. Draw the sartorius inwards, open Hunter's canal from 
above, avoiding the long saphenous nerve, free the artery, and 
pass the thread from without inwards. 

Scarpa's triangle is a space situated at the upper third of the 
anterior surface of the thigh. Base, Poupart's ligament. Outer 
boundary, inner border of sartorius. Inner boundary, adductor 
longus. Hoof, skin, superficial, deep and cribriform fascia. 
Floor, iliacus, psoas, pectineus, adductor longus, and adductor 
brevis. Apex, crossing of sartorius and adductor longus. Length, 
from base to apex, four inches. 

Hunter's canal. A triangular, aponeurotic canal, correspond- 
ing to the middle third of the thigh. Anterior, sartorius. Ex- 
ternal, vastus interims. Internal, adductor magnus, This canal 
incloses the femoral artery, vein, and long saphenous nerve. 

Collateral circulation. Common femoral. Gluteal, circumflex 
iliac and ilio-lumbar with the external circumflex. Obturator 
and sciatic with internal circumflex. At apex of Scarpa's triangle. 
Comes nervi ischiadici with arteries of the ham. Perforating 
branches of profunda femoris and anastomotica magna with 
articular arteries of popliteal, and recurrent of the anterior 
tibial. 

Popliteal. A continuation of the femoral, from the opening 
in the adductor magnus. It passes obliquely downwards and 
outwards behind the knee-joint, and ends at the lower border of 
the popliteus muscle. The artery, throughout its extent, lies in 
the popliteal space. It lies deep, and is crossed by the internal 
popliteal nerve and the popliteal vein. The nerve lies super- 
ficial to the vein, which, in turn, is superficial to the artery. 

Line. Middle of ham ; the vessel runs along the external 
border of the semi-membranous tendon. 

Belations. Upper third, from outer side, 1. Nerve. 2. Vein. 
3. Artery. Lower third from outer side, 1. Artery. 2. Vein. 3. 
Nerve. Branches, 4 articulars, 2 muscular, azygos, cutaneous. 



LIGATION OF ARTERIES 



277 



Operation. Rarely undertaken. Patient supine, leg extended. 
Incision four inches, in the line of the artery. Great care must 
be exercised in separating the vein from the artery. In opera- 
ting on the lower third, avoid the external saphenous vein. 

Collateral circulation. Articulars with anastomotica magna 
and external circumflex. Superior muscular branches with 
terminals of profund. 




The arrow marks the tendinous arch between the flexor longus pollicis and 
flexer longus digitorum, beneath which the posterior tibial artery lies. 



Posterior tibial. From the popliteal, at the lower border of 
the popliteus muscle (corresponding to the level of the lower 
part of the tubercle of the tibia), to a point a finger's breadth 
behind the external malleolus. The vessel is covered by skin 



278 ESSENTIALS OF SURGERY. 

and fascia, gastrocnemius, soleus, plantaris, and a tendinous 
arch extending between the flexor longus digitorum and the 
flexor longus pollicis. The posterior tibial nerve crosses the 
artery in its upper portion, from the inner to the outer side. 
The artery rests upon the tibialis posticus, the flexor longus digi- 
torum, and the lower end of the tibia. 

Line of incision. Upper third, along inner border of tibia. 
Middle third, one-half inch from inner border of tibia. Lower 
third (ankle), midway between internal malleolus and tendo 
Achillis. Pass the ligature from the nerve. Incision in upper 
and middle third four inches. The artery in its upper third lies 
very deep, and is secured by separating the soleus from the tibia 
working outwards in the muscular interspace between the soleus 
and the flexor longus digitorum. 

Behind malleolus. Incision two inches long, a finger's breadth 
behind the internal malleolus, convex backward. Artery lies 
beneath the deep fascia. Belations. Anterior. Tendon of flexor 
longus digitorum. Posterior. Nerve and tendon of flexor 
longus pollicis. Branches. Nutrient, peroneal, muscular, com- 
municating calcanean. 

Anterior tibial. Commences at the lower border of the pop- 
liteus muscle, passes forwards between the two heads of the 
tibialis posticus, through an opening above the interosseous mem- 
brane to the deep part of the front of the leg, descends on the 
anterior surface of the interosseous membrane (upper two-thirds), 
and tibia (lower one-third), to the middle of the bend of the 
ankle joint, where it is more superficial and becomes the dorsalis 
pedis. 

Line. From a point midway between the tubercle of tibia 
and head of fibula to the centre of the intermalleolar space. 

The ligature is passed from the outer side. 

Belations. Upper third. Between the tibialis anticus and ex- 
tensor longus digitorum. Nerve to outer side. Middle third. 
Between tibialis anticus and extensor proprius pollicis. Nerve 
in front or to inner side. Lower third. Between extensor pro- 
prius pollicis and extensor longus digitorum, or frequently as in 
middle third. Nerve to outer side. 



LIGATION OF ARTERIES. 279 

Operation. Upper third. Patient supine. Knee flexed, sole 
of Foot resting on table. Incision three inches. After opening 
deep fascia search with handle of knife for interspace between 
tibialis anticus aud extensor communis digitorum ; artery found 
between them resting on interosseous membrane. Nerve to 
outer side. Pass thread from without. The interspace may be 
defined by extending the toes and the foot in turn, thus putting 
each muscle upon the stretch. Middle and lower third, as for 
upper third, except for the changed relations. Branches. Ante- 
rior tibial recurrent, muscular, internal malleolar, external mal- 
leolar. 

Dorsalis pedis. The continuation of the anterior tibial. Ex- 
tends from the centre of the instep beneath the annual ligament, 
to the base of the metatarsal bone of the great toe, where it 
divides into the communicating and dorsalis hallucis. Its course 
is from the centre of the instep, to the space between the first 
two toes. 

It is covered simply by skin and fascia, and crossed near its 
point of bifurcation by the innermost tendon of the extensor 
brevis digitorum, which serves as a guide in its ligation. 

The ligature is passed from without inwards. The artery is 
found between the tendon of the extensor proprius pollicis and 
the inner tendon of the extensor brevis digitorum. Anterior 
tibial nerve lies to the outer side. Incision one inch long. 

External plantar artery, a terminal branch of the posterior 
tibial. Passes from the lower part of the internal lateral liga- 
ment posterior to the internal malleolus, forward and outward, 
taking a slightly arched course with the convexity outward, to 
the base of the fourth metatarsal space. This forms its superfi- 
cial part, and is covered by the fasciae and first layers of the foot 
muscles. From this point it winds round the outer border of 
the accessorius, and passes forward and inward to the posterior 
part of first interosseous space, forming the plantar arch, and 
lying upon the interossei, and bases of the metatarsal bones. 



280 ESSENTIALS OF SURGERY 



EXCISION OF JOINTS. 

What is the distinction between excision and resection ? 

Excision means the removal of the joint surfaces of bone. Re- 
section means the removal of the shaft of a long bone. 

What is arthrectomy ? 

The removal, by dissection, of the diseased synovial mem- 
brane of a joint, without interfering with the bone. 

What conditions may require excision ? 

Injury. Instance, compound luxation, compound commi- 
nuted fracture. 

Disease. Instance, tubercular synovitis or arthritis. 
Deformity. Instance, anchylosis in bad position. 

What conditions contraindicate excision ? 

Malignant growth. Acute disease. Extensive involvement of 
bone or soft parts. Extremes of age. Marked amyloid degene- 
ration. 

What precautions are observed in excising a joint ? 

The incision should be free, and in the long axis of the limb. 
Spare the bone, substituting the gouge or curette for the saw 
whenever practicable. Save the periosteum and the capsule of 
the joint, if they are healthy. Secure absolute immobility by 
splinting. 

How do you dress an excision ? 

Bone drainage-tubes, iodoform, protective, bichloride gauze, 
bichloride cotton, plaster bandage. Where a movable joint is 
desired, do not apply the fixed dressing. 

Shoulder-joint. Position of patient, on his back, the affected 
shoulder projecting beyond the side of the operating table. 

Incision four inches in length from a point slightly above and 
to the outer side of the coracoid process, downward and some- 
what outward, external to the cephalic vein. The long head of 
the biceps should be freed by a longitudinal cut. The humerus is 
rotated outwards, and the periosteum and tendon of the subscapu- 



EXCISION OF JOINTS. 



281 



Fig. 63 

ft 



laris separated by the elevator. The humerus is then rotated in- 
wards, and the periosteum and muscular attachments to the 
greater tuberosity are separated. Finally the humerus is forced 
directly upward, the posterior part of the capsule is freed by the 
periosteal elevator (avoid the posterior circumflex ar- 
tery and circumflex nerve), the bone is sawed through 
the surgical neck. A posterior opening is made for 
drainage, and the wound dressed with a pad in the 
axilla and the arm to the side. Motion as soon as 
possible. 

Elbow-joint. Incision three to four inches long, 
slightly internal to the middle line of the olecranon 
and humerus, with its central point opposite the top 
of the olecranon. Clear the olecranon of periosteum 
and soft parts with the elevator (carefully guarding 
the ulnar nerve) and saw off; now forcibly flex the hu- 
merus and clear it in the same way, sawing from 
before backward, just above the trochlear surface. 
Finally clear the ends of the radius and ulnar, and 
remove their articulating extremities just below the 
sigmoid notch and capitellum. Strip the bones sub- 



Wrist-joint. Two incisions. The radial incision, 
planned to avoid the artery, commences at the level 
of the styloid process, on the middle of the dorsal 
aspect of the radius, passes downward, parallel to 
the tendon of the extensor secundi internodii polli- 
cis, till it reaches the line of the border of the second 
metacarpal bone ; it is then carried longitudinally 
downward for half the length of the bone. 

The ulnar incision. From a point two inches above 
the lower extremity of the ulna and just anterior 
to the inner edge of the bone, downward as far as Metacar- 
the middle of the fifth metacarpal bone. 

Hip-joint. Anterior incision, three inches long, running down- 
ward and slightly outward, from half an inch below and external 
to the anterior superior spinous process of the ilium. 



282 



ESSENTIALS OF SURGERY 



Posterior incision. Begin midway between anterior superior 
spine of ilium and top of trochanter ; sweep backward and 

downward behind posterior mar- 
Fl S* 64# gin of the trochanter for about 

three inches, keeping about an 
inch back of the edge of the 
bone. Do not force the head of 
the bone from the wound, but di- 
vide in situ by a narrow saw; 
remove subsequently with se- 
questrum forceps. Curette and 
gouge away all diseased portions 
of the acetabulum, remove dis- 
eased synovia or capsule, wash 
out with zinc chloride, dry with 
bichloride sponges, dust with 
iodoform. Dress antiseptically 
and apply a double Thomas's 
splint. 

Knee-joint. Incision from the 
outer and posterior border of the 
internal condyle, to a corre- 
sponding point on the external 
condyle, curving downward suf- 
ficiently to pass midway between 
the patella and the tuberosity 
of the tibia. Dissect up the an- 
terior flap containing the patella, 
flex the joint, divide the lateral 
and crucial ligaments, clear the 
end of the femur with the finger, 
saw at right angles to its long 
axis near the upper margin of 
Butcher's saw. the cartilaginous surface. Use 

Butcher's saw, cutting from be- 
hind forward. Clear the end of the tibia, and remove its articu- 
lating extremity. Eemove by the gouge or curette all diseased 




EXCISION OF JOINTS. 283 

tissue. Suture the bone together with thick cat-gut or silver 
wire, provide for drainage, and close. Absolute fixation, plaster 
bandages if the wound remains aseptic. 

Ankle-joint. Yery rarely performed. Every effort should 
be made to preserve the periosteum. Two incisions are made. 
The fibular begins two-and-a-half inches above the tip of the ex- 
ternal malleolus, passes downward along its posterior border, 
around its tip, and upwards along the anterior border for an inch 
(hook-shaped). The tibial forms a semicircle around and just 
below the internal malleolus, from the middle of which a third 
cut runs directly upwards over the malleolus for two inches (an- 
chor-shaped). The periosteum is first raised from the fibula, 
when the bone is sawed and removed. Next, the articulating 
end of the tibia is removed ; finally the astragalus is sawn 
through. If the elevator is carefully used, the tendons and their 
sheaths will not be damaged. 



284 



ESSENTIALS OF SURGERY, 



AMPUTATIONS. 

Under what circumstances is amputation required? 

1. Avulsion of a limb. 2. Mortification. 3. Compound luxa- 
tions and fractures, if seriously complicated. 4. Extensively 
lacerated and contused wounds. 5. Diseases of bones and joints. 
6. Lesions or diseases of arteries. 7. Morbid growths. 8. De- 
formity. 

What instruments are required in amputation ? 

Tourniquets, knives, saws, retractors, tenacula, artery forceps, 
haemostatic forceps, bone-nippers, scissors, needles, and sutures. 

Describe the methods of operating. 

1. Circular. The skin is drawn upward and divided by a cir- 
cular sweep of the knife, passing entirely around the limb, and 



Fig. 65. 




Amputation by the circular method. 

dividing everything down to the muscles ; this skin cuff is further 
dissected up till its length is a little greater than half the dia- 
meter of the limb ; it is then retracted, the muscles are separated 
down to the bone by a second circular incision, and the latter is 
sawed through. 

2. Flap. There may be one or two flaps ; these may be ante- 
rior, posterior, lateral, square or oval ; they may be cut by trans- 
fixion, or from without, and may include all the soft parts (mus- 



AMPUTATIONS 



285 



culo-cutaneous), or simply the skin and superficial fascia (cuta- 
neous). 

Describe the methods of shaping the flap. 

Modified circular. Two short, curved, skin-flaps are cut, and 
the notched skin cuff is dissected up as in the circular method. 



Fig. 66. 



Fig. 67. 





Formation of flaps by transfixion. 



Teale's amputation. 



Oval and elliptical. The oval method is practically a circular 
incision, with the cuff slit at one side, and its angles rounded 
off. 

In the elliptical method the incision forms a perfect ellipse ; the 
flap is folded upon itself and sutured, making a curved cica- 
trix. 

Teale's method. Eectangular flaps, each equal in breadth ; one 
has a length of half the circumference of the limb, the other (con- 
taining the bloodvessels) is only quarter as long. 

How are amputations classified in regard to the time of ope- 
rating ? 

Primary, before the occurrence of inflammatory fever. Inter- 
mediate, during acute inflammatory fever. Secondary, after sup- 
puration has been established. 

What period is most favorable for amputation ? 

Before the occurrence of inflammatory fever. If the time for 
primary amputation has passed, wait for the secondary period. 



286 



ESSENTIALS OF SURGERY. 



What sequelae may occur after amputation? 

Hemorrhage, muscular spasm, pain, inflammation, osteomye- 
litis, protrusion of bone. 



Amputations of the Foot. 



Lisfranc's amputation. 



Fig. 68. 



Tarso-metatarsal disarticulation ; be- 
tween the metatarsal bones and the 
three cuneiforms and cuboid. 

Incision. From the base of the first 
to the base of the fifth metatarsal bone 
across the dorsum of the foot, with 
a marked convex curve downward. 
Forcibly extend and disarticulate, 
bearing in mind the backward pro- 
jection of the second metatarsal bone. 
Cut a long plantar flap. 

Arteries. Dorsalis pedis and plan- 
tar arches. 

Hey's amputation. The same as 
Lisfranc's, except that the projecting 
internal cuneiform bone is sawed 
through. 

Chopart's amputation. Intertar- 
sal disarticulation, between the as- 
tragalo-scaphoid, and calcaneocu- 
boid joint. 

Incision. From a point midway 
between the tuberosity of the fifth 
metatarsal bone and the external 
malleolus, a curved dorsal incision is made to a point one-half 
inch behind the tubercle of the scaphoid. Extend the foot, dis- 
articulate, and cut a long plantar flap. 

Pirogoff's amputation. Through the ankle-joint and os 
calcis. 

Incision, from the tip of the external malleolus, across the 
under surface of the heel, to a point half an inch below and 




L. Lisfranc's operation. H. 
The extremity of the internal 
cuneiform removed by Hey's 
operation. C. Chopart's ope- 
ration. 



AMPUTATIONS. 287 

behind the internal malleolus. Incline this cut well forward. 
Forcibly extend the foot and unite the ends of the first incision 
by a deep cut passing directly across the dorsum. Open the 
joint, draw the foot forward, place a narrow saw behind the 
astragalus and saw the os calcis through in the line of the first 
skin incision. Saw off the ends of the tibia and fibula, bring 
the heel flap up till the sawn bone surfaces are in contact, unite 
them with heavy catgut, and suture the wound. 

Syme's amputation. Through the ankle-joint. 

Incision. Inclining backward from tip of external malleolus, 
beneath the heel, to a point half an inch below and behind the 
internal malleolus. Dissect the flap from the os calcis cutting 
towards the bone. Unite the ends of the first incision by a trans- 
verse cut across the front of the ankle-joint, disarticulate, saw 
off the articular extremities of the tibia and fibula, and bring 
the flaps together. 



Amputations of the Leg. 

Lower third of the leg. By the circular, modified circular, 
bilateral tegumentary flap, Teale's method. The fibula should 
be divided first. Arteries. Anterior and posterior tibial, pero- 
neal, and muscular. 

Middle and upper third of the leg. By a long anterior tegu- 
mentary flap half the circumference of the limb in breadth and 
a little more in length. By short antero-posterior flaps. By 
lateral musculo-tegumentary flaps (Sedillot's). The projecting 
sharp edge of the tibia should be covered with a flap of perios- 
teum to prevent perforation of the anterior flap. 

Lateral double flap method (Sedillot's). A long external 
flap is formed by transfixion, and united to the short internal 
flap formed by the calf muscles. 

Lateral tegumentary flaps may be formed cutting from with- 
out inward. 

Point of election in leg amputation. Two inches below the 
tuberosity of the tibia. 



288 ESSENTIALS OF SURGERY. 



Amputations at the Knee-Joint. 

Where indicated by injury or disease this is one of the most 
successful of all leg amputations, and leaves a far more service- 
able stump than amputation in the continuity of the limb. 

Lateral flap operation. Commence the incision in the middle 
line an inch below the tubercle of the tibia, form a flap convex 
downward, carrying the point of the knife to the centre of the 
posterior surface, when it is continued directly upward to the 
centre of the articulation. The second incision begins at the 
same point as the first, and pursues the same course on the op- 
posite side of the leg to the posterior median line. The anterior 
incisions should incline forward to allow sufficient material for 
covering the condyles. The internal flap should have additional 
fulness. The patella and semilunar cartilages are allowed to 
remain. 

Long anterior flap. Incision from the lower extremity of the 
inner condyle downward for three inches, then directly across 
the tibia and upward to the external condyle. Disarticulate and 
cut a short posterior flap. 

Amputation through the femoral condyles (Carden's). In- 
cision, from the upper border of the inner, to the upper border 
of the external condyle, carried downward and across the front 
of the leg just below the insertion of the ligamentum patellae. 
Short posterior flap by transfixion. Condyles sawed across. 
The patella is not left in the anterior flap. 

Gritti's modification. Consists in sawing off the articular sur- 
face of the patella, turning it backward, and suturing it to the 
divided femur. 



Amputations of the Thigh. 

Antero-posterior musculo-tegumentary flaps. Anterior cut 
from without inwards, about four inches long, and somewhat 



AMPUTATIONS. 289 

square. Posterior flap about the same length to allow for re- 
traction, cut by transfixion. The posterior muscles of the thigh 
always retract more than the anterior group. 

Lateral flap. Teale's method or modified circular operation 
may also be done on the thigh. 



Hip-Joint Amputation. 

Hemorrhage controlled by abdominal tourniquet, digital pres- 
sure on the femoral, Esmarch's tube applied in the form of a 
spica of the groin, or by Esmarch's tube thrown above Wyeth's 
pins. 

Long anterior and short posterior flaps. Enter the knife at 
a point midway between the anterior superior spinous process 
of the ilium and the tip of the trochanter, push it directly across 
the capsule of the joint, grazing the head of the bone, till it ap- 
pears on the inner side of the thigh just in front of the tuber 
ischii ; cut directly downwards for six inches, let the femoral 
artery be seized by the fingers of an assistant, then complete the 
anterior flap by cutting outward. Turn the flap up, clear the cap- 
sule, forcibly extend the femur, and, placing the knife behind 
the trochanter, form a somewhat shorter posterior flap. First 
secure the gluteal and sciatic vessels, then the femoral artery 
and vein. The flaps may be cut from without inwards, securing 
the vessels as cut. 

Vertical and circular method. A vertical incision is made, 
from a little above the tip of the trochanter for five inches in the 
long axis of the femur. Through the incision disarticulation is 
effected, and by means of the elevator and knife the soft parts 
are separated from the bone. At the lower extremity of the 
vertical incision, skin, fascia, and muscles are divided by a 
circular sweep of the knife around the thigh, and the entire 
femur, together with the soft parts below the circular cut, is 
removed. This operation is tedious, but far more safe than the 
Rouble flap method. 
19 



290 ESSENTIALS OF SURGERY 



Amputation of the Hand. 

Phalanges. The palmar flexure is the guide to the joint sur- 
face. Flex the joint, open it by a slightly convex dorsal in- 
cision a little below its most prominent part, and cut a long 
palmar flap. The digital arteries can usually be secured by the 
skin suture. The proximal phalanx of the middle and ring 
fingers should not be saved. 

Metacarpophalangeal. Oval method (en raquette). The point 
of the knife is entered in the mid dorsal line, a little above the 
knuckle, carried first downward, then around the side of the fin- 
ger, across its web and palmar surface, and back to the point of 
starting. 

Any of the bones of the hand may be amputated through their 
continuity by either the double flap, or the oval method. 

Wrist-joint. Incision, convex downward, from styloid process 
of radius to corresponding process of ulna. Dissect up the flap, 
divide tendons, disarticulate, and cut a palmar flap from within, 
guarding against the knife catching on the pisiform bone. 



Amputations of the Arm and Forearm. 

Forearm. Modified circular, or antero-posterior flaps. Teale's 
method. 

Arteries. Anterior and posterior interosseous, radial and 
ulnar. 

Elbow-joint. The line of articulation is oblique, from with- 
out inward and downward, hence there will not be enough flap 
to cover the internal condyle if the knife is carried directly 
across the arm. 

Long anterior and short posterior flap. Flex and supinate 
the forearm, raise the soft parts from the bone, enter the knife 
an inch below the internal condyle, and push it across the limb 
close to the ulna, till it appears an inch and a half below the 



AMPUTATIONS. 291 

external condyle. Make a three-inch flap, bringing the knife 
out sharply at the finish. Draw the skin well up and unite the 
two extremities of the incision by a semilunar dorsal cut. Dis- 
articulate, either dividing the triceps, or sawing off the ole- 
cranon. 

Circular method. The incision is made three to four inches 
below the joint. 

Arm. Circular. Flap. Any of the methods. 

Shoulder-Joint. 

Oval method. (Larrey's.) Forming lateral musculo-tegument- 
ary flaps. Enter the point of the knife to the bone just below 
the acromion process, and make an incision downward in the 
long axis of the arm for about two inches. From the end of the 
incision two curved incisions are carried to the anterior and 
posterior axillary folds, respectively. These flaps are dissected 
up, and disarticulation is effected by rotating the humerus out- 
ward, and dividing first the subscapularis, then the long head of 
the biceps and capsular ligament, then rotating the humerus 
inward and dividing the insertions of the supra- and infra-spi- 
nator and teres minor muscles. The knife is now placed behind 
the bone, and the two curved incisions are joined by a trans- 
verse cut, severing the axillary artery, which is controlled by 
the thumb of an assistant before it is divided. Hemorrhage is 
checked by pressure on the subclavian, Esmarch's tube, and 
seizure of the artery in the flap before it is cut. Arteries. An- 
terior and posterior circumflex, supra-scapular, brachial. 

Single flap method. (Dupuytren's. ) A long external flap is cut 
from the deltoid muscle, either by transfixing, or from without 



292 ESSENTIALS OF SURGERY. 

TUMORS. 

What is a tumor ? 

A tumor or neoplasm is a new growth which produces local 
enlargement; which has no tendency to spontaneous cure; 
which is without physiological function ; and which tends to 

persist. 

From what do all tumors originate ? 

All tumors not of metastatic origin spring from pre-existing 
tissues, and are composed of tissue elements resembling those 
of the originating tissue, in either a mature or embryonic state. 

What is a homologous tumor ? 

A tumor composed of fully developed cells, and limited to the 
tissue from which it originates. 

What is a heterologous tumor ? 

A tumor probably embryonic in character, which is not 
limited to the tissue from which it originates, but which infil- 
trates adjacent parts. 

Mention the causes of tumors. 

Some tumors (as naevi) are congenital. In some tumors the 
tendency is inherited. Traumatism seems to bear a relation to 
the production of sarcoma. Continued irritation favors the 
development of cancer. 

What are some of the theories of tumor origin ? 

1. The inclusion theory, or embryonic hypothesis of Cohn- 
heim. This supposes tumors to arise from embryonic cells, 
which were produced in excess of foetal requirements, and re- 
mained as embryonic cells until stimulated into growth by irri- 
tation or the excitation of physiological activity. 

2. Hereditary influence. 

3. Irritation and injury. 

4. Physiological activity and decline. 

5. The theory of origin from micro-organisms (bacteria or 
coccidia), which is gaining in probability every year. 



TUMORS. 293 

What is a benign tumor ? 

An innocent or a benign tumor is composed of adult tissues 
resembling the tissues from which it springs ; it is circumscribed, 
mobile, and usually encapsuled ; it grows slowly ; it is painless ; 
it pushes aside, but does not infiltrate, adjacent tissues ; it does 
not recur after thorough removal; it does not affect related 
lymphatic glands, and does not produce a cachexia. 

What is a malignant tumor ? 

It consists of tissues embryonic in nature, widely different 
from its tissues of origin ; it is painful ;. it grows rapidly ; it is 
not encapsuled, is not mobile, and infiltrates surrounding parts; 
it affects the neighboring lymphatic glands, and gives rise to 
metastic deposits in organs; it produces a cachexia, and tends 
to recur after extirpation. 

On what does the diagnosis of a tumor depend ? 

On the age, history, sex, situation, rapidity of growth, mobil- 
ity, lymphatic involvement, physical character of growth, and 
constitutional condition. 

What rules govern the treatment ? 

Benign growths should be removed. Any benign growth 
can become malignant. These growths, as a rule, are shelled 
out of their capsule. 

A malignant growth, if seen early, is to be removed with the 
hope of cure, the adjacent lymphatics, much of the surround- 
ing tissue, and often the overlying skin being removed with the 
growth. In advanced cases we may be forced to decline ope- 
ration, but in many cases will operate, not with hope of cure, 
but to get rid of pain, ulceration, and foul discharge, allowing 
life to be more pleasantly terminated by visceral growths. 

Classification of Tumors. 

[According to American Text-Book of Surgery.) 

I. Mesoblastic or Connective-Tissue Tumors: 

A. Those conforming to the types of fully-formed conneclive 
tissue : 



294 ESSENTIALS OP SURGERY. 

1. Fibrous tumor or fibroma ; 

2. Fatty tumor or lipoma ; 

3. Cartilaginous tumor or chondroma ; 

4. Osseous tumor or osteoma; 

5. Mucous tumor or myxoma. 

B. Those conforming to the types of the higher connective 

tissues : 

1. Muscular tumor or myoma ; 

2. Warty or villous tumor or papilloma ; 

3. Vascular or erectile tumor or angeioma; 

4. Lymphatic vessel tumor or lymphangeioma; 

5. Nerve tumor or neuroma ; 

6. Lymphatic gland tumor or lymphoma ; 

7. Glandular tumor or adenoma. 

C. Those conforming to the type of embryonic connective 

tissue : 
1. Round-celled sarcoma; 
3. Spindle-celled sarcoma ; 
3. Giant-celled or myeloid sarcoma. 

D. Tumors intermediate between the sarcomata and the carci- 

nomata : 
The endotheliomata. 

II. Epiblastic and Hypoblastic Tumors — i. e. those conforming to 

the type of Epithelial Tissues : 

A. The acinous or spheroidal-celled carcinomata : 

1. Hard spheroidal-celled, scirrhous, or chronic carcinoma ; 

2. Soft spheroidal-called, encephaloid, or acute carcinoma; 

3. Colloid carcinoma. 

B. Epithelial carcinomata: 

1. Squamous-celled epithelioma; 

2. Cylindrical- or columnar- celled epithelioma. 

III. Tumors composed of Epiblastic, Hypoblastic, and Mesoblastic 

Elements : 
Teratomata, tumors containing bone, hair, teeth, etc., sit- 
uated in the ovaries or testicles. 
What do you mean by an infective granuloma ? 

An infective granuloma is a new formation composed of 
granulation-tissue, transitory in duration, terminating in ulcer- 



INFECTIVE GRANULOMA. 295 

ation or resolution, and due to the deposit and multiplication 
of certain specific micro-organisms. 

The patch of lupus, the hard or infecting chancre, the tu- 
bercle, and the lesions of leprosy and glanders are examples 
of infective granulomata. 

These tumors are locally infective, invading adjacent struc- ( 
tures, and are generally infective, involving the constitution, 
and causing in the various organs and tissues of the body new 
growths identical with or similar to the parent. 

These infective granulomata are contagious, and can be 
inoculated. 

Why is an infective granuloma not in reality a tumor ? 

Because it does not tend to persist; its duration is transitory; 
it does not form a permanent addition to the organism. 

What is a cyst? 

A sac formed of fibrous membrane, containing matter which 
is liquid or semi-liquid, or which once has been so. 

Are cysts new formations ? 

As a rule, no. 

Give the forms of cysts. 

1. Dermoid Cysts. These are due to the turning in and catch- 
ing in a foetal cleft of epithelial elements, and they are hence 
always congenital. They are lined entirely or partially with 
skin or mucous membrane, and contain often such structures 
as bones, teeth, or mammary glands (in ovarian dermoids), 
sebaceous matter, hair, sweat, etc. 

These dermoid cysts are most common about the orbit, the 
sacrum, the ovary, and the testicle. 

2. Retention Cysts. These are due to the blocking up of the 
excretory duct of a gland and the accumulation of its contents. 
Examples of this form are ranula, galactiferous cyst, and seba- 
ceous cyst. 

3. Exudation Cysts. The gathering of fluid in a cavity with- 
out any excretory duct. Examples of these are housemaid's 
knee, hydrocele, and goitre. 

4. Softening Cysts are due to the degeneration of a neoplasm, 
and are often called cystoid tumors. 



296 



ESSENTIALS OF SURGERY 



BANDAGING. 

The Roller Bandage. 

Describe the roller bandage. 

A strip of unbleached muslin, from half an inch to three inches 
in width, and from three to twelve yards in length. It may be 
made of calico, linen, or gauze. It is tightly rolled in the form 
of a cylinder ; the rolling may be from each end, forming the 
double-headed bandage. 

Name the parts of a roller bandage. 

The initial and terminal extremities, the upper and lower bor- 
ders, the internal and external surfaces, and the body of the 
roller. 

How do you apply a roller bandage? 

Fix. The body of the roller being held in the right hand, the 
external surface of the initial extremity is applied to the surface, 

Fig. 69. 




Method of applying the spiral reversed bandage. 

fixed by the thumb of the left hand till it is caught by the band- 
age carried around the limb, when it is further held in place by 
a repeated circular turn. The following turns can be made to 
overlap this circular, covering in from a half to three-fourths of 
its surface. If the part is conical, the overlapping turns may be 
made to lie smoothly by the reverse. ~"\ 

/'The circular turns are those which pass around the part, one \ 

j passing directly over the other. 

^- The spiral turns are those which pass up the limb, each one 
overlapping the other. 



— 



BANDAGING. 



297 



Fig. 70. 



t The oblique turns are those in which the bandage passes up 
/ the limb without overlapping, leaving space be- 
A tween each turn. 

s Becurrent turns are those in which the bandage 
is caught, passed to and fro, across the end of a 
stump for instance, and the loops held at the 
sides by circular turns. 

Spica and figure-of-eight turns are those in which 
the bandage forms by oblique turns two loops in 
the form of an eight. By overlapping, the crossings 
of these loops form a series of angles or spicas. 

Describe the reverse. 

Consists in folding the bandage over, so that 
the surface in contact with the skin is changed 
with each reversed turn. This is accomplished 
by relaxing all tension on the roller, carrying the 
right hand, holding the body of the roller, from 
supination to pronation, passing the body of the 
roller to the left hand beneath the limb, and 
makinar firm traction. 




Oblique band- 
age. 



For what purposes is the roller applied ? 

The general indications for all roller bandages are to retain 
splints and dressings, and to make pressure. 

Spiral of one finger. Length, one-and-a-half yards ; width, 
three-fourths of an inch. Fix by a circular turn at the wrist 
once repeated. Carry the bandage clown over the dorsum of the 
hand, and by an oblique turn to the extremity of the finger, which 
is then covered in by spiral or reversed turns as required. Com- 
plete the bandage by carrying it up to the wrist, over the back 
of the hand, and making one circular turn. 

Spiral of four fingers (gauntlet). Length, five yards ; breadth, 
one inch. Cover in each finger precisely as above, beginning 
with the little finger of the left hand, the index-finger of the 
right. As each finger is finished, the bandage is carried to the 
wrist, around, and then down to the next finger. The thumb 
may be included in this bandage if necessary. 



298 



ESSENTIALS OF SURGERY. 



Spica of the thumb. Length, three yards ; width, three-quar- 
ters of an inch. May be ascending or descending. Ascending. 



Fig. 71. 



Fig. 72. 



Fig. 73. 






Gauntlet, also taking in 
the thumb. 



Spica of thumb. 



Spiral of one finger. 



Fix at the wrist. Pass to the metacarpo-phalangeal articula- 
tion, and make a circular. Pass to the wrist again, and alter- 
nate the wrist and thumb turns so that the line of crossing is 
over the dorsum of the thumb. Overlap two-thirds from below 
upward. The descending spica has the same turns, but over- 
laps from above downward. 

Demi-gauntlet. Length, three yards ; breadth, one inch. Fix 
at the wrist, pass obliquely across the back of the hand to the 
index-finger of the right hand the little finger of the left ; pass 
around the finger, and obliquely back to the wrist. Make a cir- 
cular turn, then take in the next finger in a similar way till each 
one is encircled by a loop. 

Spiral reversed of upper extremity. Length, twelve yards ; 
width, one and one-half inches. Apply with hand in pronation. 
Fix at the wrist. Carry across the back of the hand and make 
a circular turn about the fingers at the level of the distal joint 
of the little finger. Kun up the hand with spiral reversed, or 
figure-of-eight turns, covering in the metacarpal bone of the 
thumb by means of the latter. Continue up the forearm with 



BANDAGING. 



299 



spiral turns till they cease to fit closely to the surface, when the 
reverses must be made. The elbow must be covered in by a fig- 
ure-of-eight. Do not make the line of reverses (the line of pres- 
sure) over the subcutaneous portion of the ulna. Overlap two- 
thirds. 

Spica of the shoulder. Length, ten yards ; width, two-and- 
one-half inches. Ascending or descending. Ascending. Fix by a 
circular turn about the arm placed as high as possible. Carry 
the bandage, overlapping the circular turn where it passes over 
it, across the chest (right side) or back (left side), under the oppo- 
site axilla and back to the point of starting. It is now carried 
around the arm, overlapping the circular turn, and making a spica 
directly in the middle line of the shoulder with the beginning of 
the body turn. This is repeated, passing upward till the entire 
shoulder is covered in. The descending spica is applied by the 
same turns, but runs from above downward till it reaches the 
first circular turn. 

Velpeau. Length, fourteen yards ; width, two and one-half 
inches. For the proper application of this bandage the arm 
must be placed in the Velpeau position, the hand of the in- 
jured side resting on the sound 
shoulder. 

Commence over the scapula of 
the sound side, carry the roller 
over the injured shoulder to the 
middle of the outer aspect of the 
upper arm, across the chest (be- 
hind the elbow) to the axilla of 
the sound side, thence to the 
point of starting. Repeat this 
turn to fix, then make a circular 
turn about the chest, taking in 
the elbow of the injured side. Re- 
peat these turns, first shoulder, 
then body, overlapping so that 
the shoulder turns reach the point 
of the elbow when the body turns Velpeau. 



Fig. 74. 




300 



ESSENTIALS OF SURGERY 



take in the wrist. This requires overlapping of about five-sixths 
for the vertical turns, one-third for the horizontal. Used to dress 
fractured clavicle or scapula. 

Desault. Requires three rollers. 

First roller. Length, five yards ; width, two-and-one-half 
inches. It fixes a wedge-shaped pad, base up, in the axilla. 
Four spiral turns are made, encircling the thorax and pad, the 
roller is then carried from the pad obliquely to the sound 
shoulder, about which and the pad it is made to form a series 
of spica turns. 

Fig. 76. 





Desault. First roller. 



Desault. Second and third roller 
(the second is here applied last). 



Second roller. Length, seven yards ; width, two-and-one- 
half inches. Presses the elbow to the side, and forces the 
head of the humerus outward. It consists of a number of 
circular turns embracing the arm and chest, and running from 
the head of the humerus to the elbow, overlapping one-half. 
The upper turns are applied very lightly, as they descend the 
tension on each turn is increased. 

Third roller. Length, seven yards ; width, two-and-one-half 
inches. Presses the shoulder upward and backward. Begin at 



BANDAGING. 301 

the axilla of the sound side, carry the roller obliquely across the 
chest, over the injured shoulder, down the back of the humerus, 
around the elbow of the injured side, across the chest again to 
the point of starting ; then under the axilla of the sound side, 
obliquely across the back, over the injured shoulder, down in 
front of the humerus, around the elbow, across the back to the 
point of starting. This forms two triangles, one anterior the 
other posterior. Axilla, shoulder, elbow, first in front, then be- 
hind, represent the angles of the triangles. These turns may 
overlap two-thirds, or may exactly overlie. 

Spiral of chest. Length, seven yards ; width, three inches. 
Circular around the waist, ascends to the axilla by spiral turns 
overlapping one-half. Keep from slipping down by making a 
recurrent turn across one shoulder, pinning to the circular turns, 
bringing the bandage back over the other shoulder, and securing 
it to the circular turns in front. 

Anterior figure-of-eight of chest. Length, seven yards ; width, 
two-and-one-half inches. Fix by a circular about the right arm, 
then carry the roller over the shoulder, across the chest, around 
the left shoulder, across the chest again, around the right 
shoulder, across the chest, and so continue till the required 
number of turns have been applied. Over the sternum the 
spicas may run up, overlapping three-fourths. 

Posterior figure-of-eight of chest. Length, seven yards ; 
width, two-and-one-half inches. Fix the roller upon the upper 
part of the left arm, carry it over the left shoulder, obliquely 
across the back to the right axilla, around the right shoulder, 
obliquely across the back to the left axilla, and so continue till 
ttie necessary number of turns are applied. 

Spica of breast. May be single or double. 

Single. Length, ten yards ; width, two-and-one-half inches. 
Starting from the scapula of the affected side, carry the roller 
over the shoulder of the sound side, just beneath the affected 
breast, and around the chest to the point of starting ; repeat 
this turn, then make a circular around the chest, taking in the 
lower border of the mammary gland and making a spica or cross 



302 



ESSENTIALS OF SURGERY 



Fig. 77. 




with the oblique turn. Alternate these circular and oblique 
turns, and continue them, overlapping 
two-thirds, till the gland is covered in. 
The spicas or crosses should all be in the 
same line. 

Double. Length, fourteen yards (two 
bandages) ; width, two-and-one-half 
inches. This is made up of two oblique 
turns to each circular. Start from the left 
scapula and make a repeated oblique turn, 
passing over the right shoulder and under 
the left breast as before ; then carry the 
roller around the chest as though to make 

Spica of breast (double). . , , ,.„ ., , ., ,. 

a circular turn, till it passes beneath the 
right breast, when it is carried obliquely upward over the left 
shoulder (passing above and to the inner side of the left breast) ; 
across the back, and a circular is made, just taking in the lower 
borders of the glands and making spicas with the two obliques. 
Spica of the Foot. Length, five yards ; width, two-and-a-half 
inches. Begin by a circular turn about the ankle ; pass over 
the dorsum of the foot to the metacarpopha- 
langeal articulation ; make a circular and a 
spiral turn, overlapping three-fourths, then 
carry the roller over the dorsum of the foot 
to the back of the heel, around the heel, so 
that the lower border of the bandage extends 
as low as the level of the sole, then back 
to the dorsum of the foot, crossing the begin- 
ning of the heel turn exactly in the middle 
line as it overlaps the spiral turn ; this forms 
the first spica. Again pass around the sole of 
the foot, across the dorsum of the foot overlapping three-quarters, 
around the heel, and back across the foot, making the second 
spica. So continue till the foot is covered in. Each turn of the 
bandage, after the spica is begun, must be parallel to its pre- 
decessors throughout its whole extent, and must overlap to the 
same degree. 




Spica of the foot. 



BANDAGING 



303 



Spiral reversed of the foot covering in the heel. Length, 
four yards ; width, two-and-a-half inches. Fix by a circular 
turn about the ankle, pass over the dorsum of the foot to the 
metacarpophalangeal articulation ; make a circular at that 
point, and pass up the foot by two or three reversed turns, over- 
lapping three-fourths ; having reached the top of the instep, 
carry the bandage around the point of the heel, up over the in- 
step, down around the sole of the heel obliquely, backward, and 
upward, below the malleolus, and around the back of the heel, 
forward to the instep. Again pass under the sole of the heel, 
beneath the malleolus, around the back of the heel, and forward 
to the instep. The bandage may be pinned at any point, or 
carried up the leg. 

Spiral reversed of the lower extremity. Length, twelve 
yards ; width, two-and-a-half inches. Fix at the ankle, pass 
down over the dorsum of the foot, and make a circular turn 
about the foot at the meta- 



tarso-phalangeal joint, pass lg * 

up the instep by a spiral, a 
spiral reversed, and two or 
three spica turns ; then pass 
up the leg by spiral turns, 
beginning to reverse as soon 
as the shape of the limb re- 
quires it. Cover the knee 
with a figure-of-eight, and 
ascend the thigh by spiral 
reversed turns. Overlap two- 
thirds. Do not make the 
line of the reverse over the crest of the tibia. 



Fig. 80. 




Figure-of-eight for 
the knee. 




Figure-of-eight of the knee. Length, three 
yards ; width, two-and-a-half inches. Fix by 
a circular three or four inches below the joint, 
carry the bandage upward obliquely over the 
popliteal space, and make a circular about the thigh, three or 
four inches above the joint, descend obliquely over the popliteal 



Spiral reversed 
of the lower ex- 
tremity. 



304 



ESSENTIALS OF SURGERY. 



space, and make a circular about the leg, overlapping the first 
turn upward two-thirds, ascend and make a second circular 
about the thigh, overlapping downward two-thirds. So continue 
till the joint is covered. 

Spica of the groin. Single or double. Ascending or descend- 
ing. Single ascending. Length, ten yards ; width, two-and-a- 
half inches. Fix around the upper part of the thigh (if it is the 

left side, the bandage must 
be applied throughout 
from right to left) ; carry 
obliquely across pubes, 
lower part of abdomen 
and crest of ilium, around 
the back, and down to 
the starting-point, passing 
across the front of the 
thigh, and forming the 
first spica turn, which 
should be within the mid- 
dle of the anterior surface 
of the thigh ; repeat these 
turns, overlapping two- 
thirds in the groin, but 
converging as the bandage 
is carried to the crest of 
the ilium, till they overlie 
in the back. 

Remember that in all 

ascending spica bandages, 

the position of the crossing 

is determined by the lower 

border of the bandage ; in 

all descending spicas, the upper border determines the position 

of the turns. A well-applied spica should have all the angles 

of crossing exactly in line. 

Double ascending spica. Length, fourteen yards ; width, two- 
and-a-half inches. Fix by a circular around the waist, carry 




Spica of groin. Single ascending. Should 
be started around the thigh. 



BANDAGING 



305 



obliquely downward across the belly, pubes, and left thigh ; 
around the left thigh, and up to the left iliac crest, forming the 
first spica ; around the back, and obliquely down, across, and 
around the right thigh, forming the second spica; obliquely 
across the belly to the left iliac crest, forming with the first 
oblique abdominal turn the third spica. Repeat these turns, 
taking in body, left thigh, body, right thigh, and overlapping 
two- thirds. There are three sets of crossings : one in the middle 
line of the belly, and one within the middle line of each thigh. 

Descending single and double spicas of groin. The turns are 
the same as for the ascending spicas, except that the first turns 
are placed at the highest point which it is desired to cover by the 
bandage, and the spicas are made by the upper border of the 
bandage. 



Head Bandages. 



Barton's. Length, five yards ; width, two inches. Begin be- 
hind the ear (left if standing behind the patient, right if stand- 
ing in front) ; carry the roller 
down under the occiput, and up Fig. 82. 

to a corresponding point behind 
the other ear; thence directly 
across the vertex, down the side 
of the face, under the chin, up the 
other side of the face to the ver- 
tex, making an intersection with 
the former turn directly in the 
middle line ; then to the point of 
starting, around under the occi- 
put, forward along the body of 
the jaw, around the symphysis 
menti, back along the jaw on the 
other side, to the point of starting. 
Exactly repeat these turns three 

times. Application. Fracture of Barton's bandage, 

jaw. 

20 




306 



ISSENTIALS OF SURGERY 




Gibson's bandage. Vertical 
turn should be made first. 



Gibson's. Length, five yards ; width, two inches. Make 
three vertical turns, passing under 
the chin, along the sides of the face 
in front of the ears, and over the top 
of the head ; reverse just above the 
ear, and make three circular turns 
about the forehead and occiput ; as 
the third turn is completed, carry the 
bandage beneath the occiput, under 
the ear, along the body of the jaw, 
around the symphysis menti, and take 
in the front of the chin and the sub- 
occipital region with three turns ; re- 
verse beneath the occiput, carry the 
roller directly forward in the middle 
line to the forehead, pin all intersec- 
tions. 

Oblique of the jaw. Length, five yards ; width, two inches. 
Face the patient, begin the bandage in the middle of the fore- 
head and carry it towards the injured side. Fix by a circular 
fronto-occipital turn. Carry the roller obliquely down beneath 
the occiput, around the front of the neck to the angle of the 
injured jaw, then up the side of the face (in front of the ear), 
across the vertex, down the side of the head behind the ear of 
the sound side, under the chin, and up again on the injured side, 
overlapping the preceding turn forward three- 
quarters. The turns behind the ear of the 
sound side do not overlap. 

Application. For fracture of the condyle 
of the jaw, or fractures with marked lateral 
deformity. 

Recurrent of scalp. Length, seven yards ; 
width, two inches. Fix by a circular fronto- 
occipital turn, then reverse, catch the point of 
reverse with the finger and pass directly from 
occiput to brow across the top of the scalp. 
The bandage is held in front by an assistant 



Fig. 84. 




BANDAGING. 307 

and carried back again overlapping the first recurrent turn two- 
thirds ; it is carried to and fro in this way till the scalp is entirely 
covered, when the loops are fixed at the sides by circular turns. 

Figure-of-eight of the eye. Single and double. 

Single. Length, five yards ; width, two inches. Fix by a 
circular fronto-occipital turn, beginning in the middle of the 
forehead and carrying the bandage away from the injured eye. 
As the bandage passes backwards for the third turn, carry it ob- 
liquely downward across the occiput, under the ear of the affected 
side, obliquely upward over the ramus of the jaw and the 
affected eye, to the most prominent part of the parietal bone ; 
thence to the starting-point of the oblique turn, which is to be 
repeated two or three times and fixed by a fronto-occipital 
circular. This bandage may also be applied by alternating 
circular and oblique turns, overlapping upward or downward 
and making a series of spicas. 

Double. Length, seven yards ; width, two inches. One eye 
may be covered as in the single bandage, then the other in a 
precisely similar manner ; or the turns may alternate and over- 
lap, forming a series of spicas over the bridge of the nose. 

Occipito-facial. Simply the vertical and circular occipito- 
frontal turns of the Gibson bandage. Pin all intersections. 

Fronto-occipito-cervical figure-of-eight. Length, three yards ; 
width two inches. Fix by a fronto-occipital circular turn, carry 
obliquely downward across the occiput to the neck, around the 
neck, obliquely upward across the occiput, around the forehead, 
obliquely downward and around the neck ; so continue till 
the bandage is completed. 

Fronto-occipito-mental figure-of-eight. Length, three yards ; 
width, two inches. Apply as the preceding bandage, except that 
the turn is carried around the chin instead of around the neck. 



Handkerchiefs. 

Describe the handkerchief bandage. 

This consists of a thirty-two inch square piece of muslin, 
calico, or any soft strong material, forming the square. 



308 ESSENTIALS OF SURGERY. 

The triangle is formed by bringing the two opposite angles of 
the square together. The parts of the triangle are, the base, the 
apex (the angle opposite the base), and the angles or ends. 

The cravat is formed by folding the triangle once or twice 
from its apex towards its base. 

Handkerchief bandages receive a double name, the first being 
the part to which the base is applied, the second the part around 
which the ends are carried. 

The simple bandage is that made up of a single handkerchief; 
the compound bandage is that made up of more than one hand- 
kerchief. 



Handkerchief Bandages of the Head. 

Occipito-frontal triangle. Apply the base to the occiput, 
letting the apex fall over the forehead. Carry the two ends 
forward around the head and tie in front, or cross, and pin at 
the sides. Turn the apex up and pin to the body of the band- 
age. 

Fronto-occipital triangle. As the preceding, except that the 
base is applied to the forehead, and the apex falls over the 
occiput. 

Bi-temporal triangle. As the preceding, except that the base 
is applied over one temple, the. apex falls over the other. 

In the choice of these three bandages, the base is applied over 
the seat of injury, or where most pressure is desired. 

Vertico-mental triangle. Apply the base to the vertex with 
apex back ; carry the ends down under the chin, and either tie, 
or cross and pin. Bring the apex to one side and pin. 

Auriculo-occipital triangle. This does not conform to the 
rule in naming. Place the base in front of the ear, apex back, 
carry one end under the chin, the other over the top of the 
head and tie or pin in front of the ear on the sound side. 

Square cap. Fold the handkerchief so that a quadrilateral is 
formed, with one border overlapping the other three inches. 
Apply this quadrilateral to the scalp with the projecting border 



BANDAGING. 



309 



next the surface and hanging over the forehead. Bring the 
ends of the short fold under the chin and tie. Fold back the 
long border exposing the forehead, pull the ends forward till 
the bandage fits about the head, then carry them back and tie 
beneath the occiput. 



Fig. 85. 



Fig. 86. 





Beginning of square cap of head. 



Square cap of head completed. 



Fronto-occipito-labialis cravat. Fold the triangle into a cravat. 
Place the body upon the forehead, carry the ends back, cross at 
the back of the neck, and bring them forward, tying or pinning 
over the upper or lower lip, as required by the injury. Used to 
approximate lip wounds, and to check bleeding from the coronary 
arteries. 

Occipito-sternal triangle (compound). Apply a sterno-dorsal 
(straight around) cravat about the chest. Flex the head upon 
the chest and apply the base of a triangle, apex forward to the 
occiput, carry the two ends down to the sterno-dorsal cravat and 
secure. The apex of the triangles may be folded back and 
pinned. Used in cut throat wounds of the neck. 

Parieto-axillaris triangle (compound). Apply an axillo- 
acromial cravat (around the shoulder). Place the base of a tri- 
angle over the parietal eminence of the opposite side, carry the 
ends around the head and cross them ; incline the head laterally, 
and secure the ends of the triangle to the shoulder cravat. 

Used to approximate w r ounds at the side of the neck. 



310 



ESSENTIALS OF SURGERY 



Handkerchief Bandages of the Trunk. 

Axillo-cervical cravat. Place the body of the cravat in the 
axilla, carry the ends over the shoulder, across each other, and 
around the neck. 

Used to retain dressings in the axilla. 

Bis-axillary cravat (simple). Place the body in the axilla, 
cross the ends over the shoulder and carry one across the chest, 
the other across the back, to the axilla of the opposite side, 
where they are tied or pinned. 

Used as the preceding bandage. 

Bis-axillary cravat (compound). Place the body of one cravat 
in the axilla, carry its ends over the shoulder and tie (axillo- 
acromial cravat). Place the body of another cravat in the 
opposite axilla, and carry the ends obliquely across the chest 
and back to the first cravat, tying them together when one end 
has passed through the loop of the first cravat. 

Used to retain dressings in both axillas. 



Fig. 87. 



Bis-axillo-scapulary cravat (simple). Place the body to the 

front of the shoulder, with the 
lower end one-third longer than 
the upper. Carry the upper end 
over the shoulder, the lower end 
under the axilla, obliquely across 
the back to the opposite shoulder, 
around it, and back to the short 
end, to which it is tied. This 
forms a posterior figure-of-eight, 
and is used as a temporary dress- 
ing for fractured clavicle. 

Bis ■ axillo - scapulary cravat 
(compound). Loop one cravat 
loosely about the shoulder, and 

Bis-axiHoscapulary cravat (com- tie ' PlaCe the body of the other CTa- 

pound). vat in front of the opposite shoul- 




BANDAGING. 



311 



der, carry the ends back, one over the shoulder, the other through 
the axilla. Tie in a single loose knot, carry one end through the 
loop of the first cravat, and tie in a double knot. 

Used to draw the shoulders forcibly back, as in fracture of the 
clavicle. 

Dorso-bis-axillary triangle (compound). Breakfast shawl. 
Carry a cravat around the chest and tie in front (dorso-ster- 
nal). Place the base of a triangle, apex down, on the back of 
the neck, carry each end over the corresponding shoulder, and 
tie to the dorso-sternal cravat in front. The apex is fastened 
around the body of the cravat behind. 

Used to retain dressings to the shoulder or back. 

Mammary triangle. Place the base of the triangle under the 
breast, and its apex over the shoulder of the same side. Carry 
one end across the opposite side 
of the neck, the other under the Fig. 88. 

axilla of the affected side. Tie at 
the back, and secure the apex be- 
neath the knot. 

Used to support the breast, to 
make pressure, to retain dress- 
ings. 

Scroto-lumbar. Tie a cravat 
about the waist. Place the base 
of a triangle beneath the scrotum, 
carry the two ends up and secure 
them to the cravat. Finally se- 
cure the apex by carrying it un- 
der the cravat, folding it in front, and pinning. 

Used as a suspensory of the scrotum. 

Abdomino-inguinal (simple). For this bandage one long cra- 
vat may be made by tying two together. Place the body of the 
cravat back of the thigh in such a manner that one end may be 
two-thirds longer than the other. Bring the ends to the front, 
cross over the groin, and carry them around opposite sides of 
the body, knotting or pinning in front. 




Mammary triangle. 



312 



ESSENTIALS OF SURGERY. 



Fig. 89. Used as the spica of the groin, to retain 

dressings on bubos, or make pressure upon 
them. 

Abdomino-inguinal (compound). Place 
the centre of the cravat (three, knotted or 
sewed together) over lumbar vertebrse, 
carry the two ends forward on each side 
just below the iliac crests, obliquely down- 
ward and inward over the front of the 
groins, backward between the thighs, out- 
ward around each thigh to the front ; cross 
over the pubes and pin to the body of the 
Gluteal triangle. Cravat. 

Gluteal triangle (compound). Tie a cravat about the waist. 
Place the base of a triangle obliquely at the gluteal fold, and 
tie the ends around the thigh. Carry the apex up and under 
cravat, fold it over, and pin. 

Used to retain dressings to the gluteal region. 




Handkerchief Bandages of the Extremities. 

Palmar triangle. Place the base of the triangle on either the 
palmar or dorsal surface of the wrist, fold the apex over the hand 
and back to the wrist, carry the ends around the wrist and apex 
and tie, fold the apex back, and pin to the body of the bandage. 

Triangular cap of the shoulder. 1. Place the base on the 
shoulder, apex hanging down over the arm ; carry the ends under 
the axilla, across each other, around the arm, taking in the apex, 
and tie. Fold* the apex upward, and pin to the body of the 
bandage. 

2. Place the base of the bandage on the upper part of the arm. 
with the apex covering the shoulder ; carry the ends around the 
arm, across each other in the axilla, and up around the shoulder, 
taking in the apex. Fold the apex down and pin. Used to re- 
tain dressings to the 'upper part of the arm or shoulder. 



BANDAGING 



313 




Triangular cap of a stump. Place the base under the stump, 
carry the apex over its end. Secure the apex by carrying the 
ends around the limb, and pinning or knotting. Fold the apex 
up, and pin to the body of the bandage. 

Cervico-brachial triangle. Sling of the arm. Place the base 
of a triangle at the wrist of the 
flexed forearm, carry the ends 
over the shoulders, around the 
back of the neck, and tie. Draw 
the apex back beyond the elbow, 
fold it posteriorly, and pin it in 
this position. If the triangle is 
not long enough, a cravat may be 
tied loosely around the neck, and 
the ends of the triangle knotted 
in this. 

Metatarso-inalleolar cravat. 

Place the body obliquely across 

the back of the foot, carry one 

end around the foot, the other around the ankle, and tie in front, 

ovex* the back of the foot. 

Malleolo-phalangeal triangle. Place the base in the hollow 
of the foot. Fold the apex around the toes and in front of the 
ankle-joint. Carry the ends around the foot, cross on the 
dorsum, and continue around the malleoli ; then back to the 
dorsum, securing here, or continuing to the side and pinning. 

Cervico-tibial triangle. Carry a cravat from the top of the 
shoulder of the sound side to the axilla of the injured side, around 
the body to the point of starting, and tie. Flex the leg and place 
the base of a triangle on the tibia just above the ankle. Carry 
the ends up and tie through the cravat. Bring the apex around 
the knee, and pin to the body of the handkerchief. Used to sup- 
port the leg when it is fractured, and the patient is required to 
walk. 

Figure-of-eight of the knee. Place the body of the cravat just 
above the patella, carry the ends back, cross in the popliteal 



Cervico-brachial triangle. 



314 ESSENTIALS OF SURGERY. 

space, bring them forward just below the patella, and tie. Used 
to approximate the fragments of a fractured patella. 

Tarso-patellar cravat. Place one cravat as a figure-of-eight 
of the knee, loop another cravat around the foot, just anterior 
to the ankle ; catch the body of the third cravat through this 
loop, and carry its ends under both the lower and upper seg- 
ments of the figure-of-eight, and secure by pinning. Used to 
approximate the fragments of a broken patella. 

Tibial cravat. Place the body obliquely across the calf, carry 
the ends around the leg, one below the patella, the other above 
the malleoli. Used to retain dressings. 

Barton's cravat. Place the body of the cravat around the 
point of the heel, with the end corresponding to the outer side 
of the foot one-third longer than the other. Hold the inner end 
(short) parallel with the foot, while the long end is carried across 
the instep, turned once around the inner end, back under the 
sole of the foot, and looped around itself as it crosses obliquely 
over the instep. The two ends are knotted, drawn upon, and 
the cravat so arranged that traction exerts equal pressure upon 
dorsum and heel. Used to make extension for fractured femur. 



ESSENTIALS OF SURGERY. 315 



THE RONTGEN RAYS. 

In December, 1895, Professor Rontgen of Wiirzburg made 
public his discovery of the capacity of the rays formed in a 
Crookes tube to penetrate many opaque bodies. Some bodies 
permit the passage of the rays ; other bodies do not. A body 
that intercepts the rays casts a shadow, and the outlines of the 
shadow can be photographed upon a sensitized plate. These 
pictures are spoken of as "skiagraphs" or "shadowgraphs." 
If the Crookes tube is placed opposite a body, and an individual 
tries to see through the body by means of the unaided eyes, he 
is unable to do so ; but if the person interposes between his 
eyes and the body fluorescent materials, the outlines of certain 
substances become perfectly apparent. An instrument contain- 
ing this fluorescent matter is called a " fluoroscope," a "skia- 
scope," or a " cryptoscope." The first fluoroscope was a brass 
tube blackened on the inside, to one end of which was fastened, 
by means of non-actinic black photographic paper, a disk of 
paper containing the double cyanide of barium and potassium. 
The other end of the tube is applied to the eye, and the tube is 
pointed toward the vacuum tube. The z-rays fall upon the 
fluorescing screen, causing it to glow, and thus show the 
shadows of certain objects between the Crookes tube and the 
fluoroscope. Edison's fluoroscopic paper contains crystals of 
tungstate of calcium. 

The z-rays are very useful to the surgeon. They are valuable 
in the diagnosis of fractures and dislocations and of diseases 
and deformities of bones. We can even examine a fracture 
after dressings have been applied, and be sure that the ends are 
in apposition. They are valuable in studying the changes that 
bones undergo when subjected to mechanical treatment by or- 
thopedic appliances. They are of great use in locating foreign 
bodies imbedded in the tissues or lodged in the oesophagus, the 
air-passages, or the eye. Foreign bodies within the cranium 
have been discovered, and" foreign bodies lodged in bone can 
be detected. Thoracic aneurysm has been skiagraphed. The 
outlines of the stomach have been observed by making the 



316 THE RONTGEN RAYS. 

person drink lime-water before using the z-ray apparatus. 
Stones in the ureter, kidney, and gall-bladder have also been 
observed. 

The normal structures of the body, except the bones, permit 
the passage of the rays; hence at present the new discovery 
does not afford much information about them. 

This method is still in its infancy, and to what extent its use- 
fulness will reach no man can at present guess. 



AN APPENDIX 

CONTAINING 

FULL DIRECTIONS AND PRESCRIPTIONS FOR THE PREPARATION 
OF THE VARIOUS MATERIALS USED IN ANTISEPTIC SUR- 
GERY. ALSO SEVERAL HUNDRED RECEIPTS COVERING 
THE MEDICAL TREATMENT OF SURGICAL AFFECTIONS. 



ABSCESSES. 

R.. Calcii sulphidi, gr. j 

Sacch. lactis, gr. x. 

Et ft. chart. No. x. M. 

S. Take one powder every one or two 
hours. (Ringer.) 

R. Sodii hypophosphitis, 9iv 
Calcii hypophosphitis, 9viij 
Syrupi siniplicis, fSiss 

Aquae fceniculi q. s. ad. fsiv. M. 

S. Two teaspoonfuls four times a day. 
(Churchill.) 



gr. viij 
fSj. M. 



R. Acidi carholici, 

Aquae destil., 
S. Inject "5x into swelling and repeat 
every three days. 

R.. Iodoformi, 5j 

Glycerinae, 3j. M. 

S. Inject into the abscess cavity after 
evacuating the pus. (Billroth.) 

BOILS (See Abscesses). 

BUBO. 
R. Tr. iodi, f5j. M. 

S. Paint well every other day until 
skin becomes tender. (Van Buren.) 



R. Acid, carbolic, gr. viij 

Aquae destil., isj. M. 

S. Inject ten minims into gland after 
having used ether spray. Repeat, if 
necessary, in three days." 



R. Hydrogen peroxide (Mar- 

chand's solution), fSvj. M. 
S. Apply with an atomizer after sup- 
puration has begun. (Ringer.) 

BUNIONS. 
R. Tr. iodi, 

Tr. belladonnas, aa 5ij. M. 
S. Apply twice daily with a brush. 



R. Argent, nitratis, 

Aquae, 
S. Paint twice daily. 



5j 
fSj. M. 



BURNS. 
Wash with 1-4000 bichloride lotion; 
dust lightly with iodoform ; apply pro- 
tective and dress antiseptically. Or, 
instead of the antiseptic dressing, use 
R. Acidi borici, 5j 

Ung. petrolati, 5j. M. 

S. Apply on lint. 



R. Ung. hydrarg., 

Ammon. chlorid., 
S. Apply twice daily. 

R. Cadmii iodid., 

Adipis, 
S. Apply twice daily. 



5ij 

5j. M. 
(Dupuytren.) 



XXX 

M. 



R. Acidi borici, 5j 

Aquae, Siv. M. 

S. A piece of oiled silk a trifle larger 
than the lesion is dipped in the solu- 
tion and applied ; then a larger piece 
of lint, dipped in the same solution, 
placed over the silk and held loosely 
by a bandage. (Lister.) 



317 



318 



SURGERY. 



R. 01. lini 

Liq. calcis, aa fgij 

Acidi carbolici, gtt. xv. M. 

S. Wring out dressings of sterile gauze 
in this mixture and apply. 

(Charity Hospital, N. Y.) 

R. Acidi carbolici, gr. viij 

Vaselin., Sij. M. 

S. Spread on lint and apply where 
the skin is broken. 

(Bellevue Hospital, N. Y.) 

R. Cerati resinse, Sij 

01. terebinth., f3ij 

Phenol sodique, f3j. M. 

S. Apply on linen or lint. (Read.) 

R. Sodii bicarb., gij 

Aquae, Oij. M. 

S. Apply freely, on lint. 



R. Cerati resinse, 

01. terebinth., 

S. Apply on lint. 



R. Acidi salicylici 
01. olivae 



5j 

f3j. M. 
(Agnew.) 



5j 
fSiij. 



M. 



S. Apply to burn, covering with lint, 
(Bartholow.) 



CARBUNCLE. 

R. Acidi carbolici, gr. viij 

Aquse destil., fsj. M. 

S. Make several injections into differ- 
ent parts of the induration. Not more 
than 5j of this solution should be used 
at one treatment. The injection may 
be repeated, if necessary, in three days. 



R. Tr. iodi, f3%. M. 

S. Paint around the carbuncle until 
vesication is produced. 

(Furneaux Jordan.) 



R. Pulv. opii, 

Unguent, hydrarg., 

Saponis durse, aa V/*. M. 
S. Apply spread on thick leather. 



Apply a flaxseed poultice, over the 
centre of which has been spread a little 
coarsely-powdered crude soda. Subse- 
quently dress with compound resin 
ointment, which should be applied very 
warm and should be covered with oiled 
silk. Change the dressing every six 
hours. (Agnew.) 



CARIES. 
R. Syrup, hypophos. comp., 
(N. F.), 
01. morrhu., aa fjiv. M. 

S. 3ij four times daily. 

R. Syrup, calcii lactophos- 

phat. (U. S. P.), fsvj. M. 

S. A teaspoonful three or four times a 
day. (Bartholow.) 

R. Hydrogen peroxide (Mar- 

chand), fSvj. M. 

S. Apply with an atomizer or small 
syringe. 

R. Cupri sulphat., 

Zinci sulphat., aa gr. xv 
Liq. plumbi subacetat., i'3ss 
Aceti alb., fsiiiss. M. 

S. Inject through the sinuses. 

(Liqueur de Villate.) (Notta.) 

CHANCRE. 
R. 01. lavand., ' "Kxx 

Iodoformi, 

Lycopodii, aa Sij. M. 

S. Dust on part and cover with lint. 

R. Cupri subacetat., 

Hydrarg. chlor. mit., aa gr. x. M. 
S. Dust over sore. (Ellis.) 



gr. viij 
fSij. M. 



R. Hydrarg. chlor. mit., gr. vii 

Liq. calcis, fgij. 

S. Shake and use as a wash. (Black 
wash.) 

R. Hydrarg. chlor. corros., gr. iv 

Liq. calcis, f3ij. M. 

S. Shake and use as a wash. (Yellow 
wash.) 

R. Hydrogen peroxide, f3j. M. 
S. Use as a wash and apply on lint. 
If too strong, may be diluted. 

(Ringer.) 

CHANCROID. 
Actual cautery and dress antisepti- 
cally. 

R. Acidi sulphurici, 

Pulv. carbonis ligni, aa 5ss. 
q. s. ft. magma. M. 

S. Dry the sore and apply thoroughly 
by means of a wooden spatula. Allow 
artificial eschar thus formed to separate 
spontaneously, using no dressing. 

(Ricord.) 



SURGERY. 



319 



Cauterize with nitric acid, protecting 
the surrounding parts by oil. 

R. Iodoform., 5ij 

01. menth. pip., "Ux. M. 

S. Dust on sore and cover with moist 
lint. 

R. Bismuth, subiodid., 3ij. M. 
S. Dust on sore and cover with dry 
lint. (Chassaignac.) 

R. Pulv. acidi salicylici, 5ij. M. 
S. Dust on sore and cover with dry 
lint. (Anglada.) 

CHORDEE. 
Hot sitz bath for one-half to one hour 
before retiring, or steeping penis for the 
same length of time in hot water. 



R 


Ext. opii, 




gr. 


vj 




Ext. hyoscyami, 




gr. 


iij 




01. theobrom. q. s 






M. 




Et ft. suppos. No. 


vj. 






s. 


Introduce one into the rectum at 


bedtime, and repeat if 


necessary 




R. 


Ext. opii, 




gr. 


vj 




Ext. belladon., 




g r - 


iss 




01. theobrom. q. s 
Et ft. suppos. No. 






M. 




vj. 







S. Introduce one into the rectum at 
bedtime. 



R. Ext. opii aquos., gr. ix 

01. theobrom., q. s. M. 

Ft. suppos. No. vj. 
S. Introduce one into rectum on re- 
tiring. (Van Buren and Keyes.) 

R. Liq. morph. sulph., f3iv 

Atrop. sulph., gr. j 

Acidi aceti, q. s. 

Aquae destil., q. s. ad. fsj. M. 

S. Five to eight minims hypodermi- 
cally at bedtime. (Sturgis.) 

R. Ext. opii., gr. iv 

Pulv. camphorae, gr. viij. 

Et ft. pil. No. iv. M. 

S. One or two pills on retiring. 

(Van Buren and Keyes.) 

R. Sodii bromidi, 5ij to iv 

Camphor., 

Lupulin., aa gr. x. to xx 

Ft. chart. No. x. M. 

Put in waxed papers. 
S. One powder morning and evening. 
(Finger.) 



R. Pulv. opii, gr. vj 

Pulv. camphorae, gr. xij 

Sacch. alb. q. s. M. 

Et ft. capsul. No. vj. 
8. One at bedtime, and repeat in two 
hours if necessary. (Sturgis.) 



CYSTITIS. 
Hot sitz baths one-half to one hour, 
t. d. 



Hot flaxseed-meal poultices over lower 
abdomen. 

R. Tr. aconit., f3j 

Spts. aeth. nitros., fsj 

Liq. potass, cit., q. s. ad. fSvj. M. 
S. One dessertspoonful every four 
hours until all fever ceases and the 
pulse is quiet. (Hare.) 

R. Potass, bicarbonat., 5iv 

Ext. hyoscyami fl., f5ij 

Ext. ergot, fld., f3iy 

syrup, simp., fSij 

Aquae, q. s. ad., fSvj. M. 

S. A dessertspoonful every two to four 
hours. 

R. Infus. buchu, fSvij 

Potass, bicarb., 5j 

Tr. hyoscyami, f3ijss 

Ext. sarsa fl., f5iv. M. 

S. Two tablespoon fuls three times a 
day. (In irritable bladder with acid 

urine.) (Coulston.) 

R. Potass, citrat., Sss 

Spts. chloroformi, f3ijss 

Tr. digitalis, "51xxx 

Infus. buchu, fSviij. M. 

S. Two tablespoon fuls three or four 

times a day. (Fothergill.) 

R. Copaibae, 

Spts. lavan.comp., aa f3ij 
Mucil. acaciae, fSss 

Syrup, simp., f3iij 

Aquae, fSiv. M. 

S. A tablespoonful twice daily. 

(Wood.) 

R. Atropinae sulph., gr. j 

Acidi acet., gtt. xx 

Alcoholis, 
Aquae, aa fSss. M. 

S. Four drops in a wineglass of water 
before each meal. 

R. Salol, 5j 

Ft. capsul. No. xij. M. 

S. One capsule three times a day up to 
two six times daily p. r. n. 



320 



SURGERY. 



R. Acid, boric, 5j 

Aquae, q. s. ad. fgvj. M. 

S. Two tablespoonfuls three to four 
times a day. 

R. Phenol sodique, fSij. M. 

S. Add two tablespoonfuls to a pint 
of warm water and inject into the 
bladder once or twice a day. 

R. Potass, permanganat., 5j 

Aquae, fsj. M. 

S. Add one teaspoonful to a pint of 
warm water and inject into the bladder 
once or twice a day. 

R. Acid, boric, 5iv 

Aquae destil., Oj. M. 

S. Warm and inject into the bladder 
once or twice daily. 

R. Argent, nitrat., gr. vij 

Aquae destil., fsiijss. M. 

S. Inject into the bladder every third 
or fourth day, after washing it out with 
warm water. 

For profuse suppuration : — 
R. Hydrogen peroxide (Mar- 

chand), fSss 

Aquas destil., q. s. ad. fSiv. M. 
S. Inject daily, increasing the strength 
of the solution if it does not give pain. 

EPISTAXIS. 

R. 01. erigeron. canad., f5ij. M. 
« I?;™ a™„* ~„ o „ — fifteen 



. KJl. CllgClUU. UitllitU., l C>lJ- J- 

S. Five drops on sugar every lift 
minutes as required. (Willard 



R. Ext. hamamel. fl., fSij. M. 

S. A teaspoonful every one to three 
hours. (If pulse is rapid and bounding 
add veratrum viride and morphine.) 
(J. V. Shoemaker.) 



R. Pulv. acid, tannic, 5ij. M. 

S. Insufflate after a small quantity of 
cocaine has been applied. (Ingalls.) 



R. Pulv. aluminis, 

Pulv. acid, tannic, aa 5j. M. 

S. Insufflate into the anterior and 
posterior nares. (Sajous.) 

ERYSIPELAS. 

R. Tr. ferri chlor., 

Syr. simp., aa f5j 

Aquas, fSij. M. 

S. A teaspoonful every two or three 
hours, well diluted. 

(Charity Hospital, N. Y.) 



R. Potassii permanganat., gr. vj 

Aquae destil., ?3vj. M. 

S. A tablespoonful three times a day. 
(Keep in glass-stoppered bottle.) 

(Bartholow.) 

In the early stage, in plethoric cases, 
DaCosta recommends pilocarpine in 
sweating doses (% to % gr. hypodermi- 
cally). 

R. Campho-phenique, fSij. M. 

S. Scarify the affected area, particu- 
larly at the spreading borders of in- 
flammation and slightly beyond, and 
apply gauze or lint wrung out in this 
medicament ; or it may be applied 
without scarification. 



R. Ichthyol., 

Vaselin., aa Sss. M. 

S. Wash thoroughly with hot soap- 
suds and apply on lint thickly spread. 
(Nussbaum.) 

R. Argent, nitrat., gr. lxxx 

Aquae destil., fgiv. M. 

S. Paint two or three times all over 
and a little beyond. (Higginbottom.) 



R. Plumb, acetat., 5j 

Tinct. opii, fsj 

Aquae, q. s. ad. Oj. M. 

S. Shake the bottle well and wet 
cloths or lint thoroughly with the lo- 
tion and apply to the affected parts. 
(Charity Hospital, N. Y.) 



FISSURE. 

R. Ext. hydrastis fl., 
S. Apply to fissure. 



fSj. M. 
(Bartholow.) 



R 



Acidi carbolic, gr. xxiv 

Aquae, f3j. M. 

S. Apply several times daily. 

(Parvin.) 

R. Cocaine hydrochlor., gr. iv 

Aquae destil., fsj. M. 

S. Apply to nipples and wash off well 
just before nursing. 



If the fissure is deep and slow to heal, 
touch with solid stick nitrate of silver. 



R. Bismuth, subnit., 5j 

01. ricin.. foij. M. 

S. Rub in affected parts. (Hirst.) 



SURGERY. 



321 



R-. Potassii bromid., 

Glyceriui, 
S. Apply locally. 



Sj 

f5v. M. 
(Ringer.) 



R. Iodoform., 

Acid, tannic, aa 5j. M. 
S. Fill fissure with the powder and 
dust over it. (Bartholow.) 

R-. Plumb, nitrat., gr. x 

Glycerini, fSj. M. 

S. Apply after each nursing, carefully 
washing before next nursing. 

FISTULvE. 

R. Hydrogen peroxide, fSvj. M. 
S. Inject once daily ; dilute if neces- 
sary. 



R-. Cupri sulphat,, 

Aquae, 
S. Inject once daily. 



^r. ij to iv 
'3iv. M. 



(Sir A. Cooper.) 

R-. Argent, nitrat., gr. ij 

Aquae destil., fSviij. M. 

S. Inject once daily. (Fistula in ano.) 
(Druitt.) 

R. Tr. iodi, f5j. M. 

S. Inject once daily. (Waring.) 

Touch with solid stick of argent, nit. 

GLANDS, ENLARGED. 

IJ.. Syr. ferri iodid., fsj. M. 

S. Five to thirty drops, well diluted, 
after each meal. 

Ifr. Oleat. hydrarg. (U. S. P.), Sj. M. 
S. Rub over the enlarged glands once 
daily. 

R. Tr. iodi., f3j. M. 

S. Paint over enlargements thoroughly 
and repeat as soon as the dark color com- 
mences to disappear. 



I£. Cadmii. iodid., gr. xxtoxxx 

Adipis, 3j. M. 

S. Apply morning and evening. 

R-. Ichthyol., 5iij 

Adipis, 5vij. M. 

S. Use as inunction morning and even- 
ing. (Agnew.) 

R% Acidi carbolici, gr. viij 

Aquae destil., isj. M. 

S. Inject five to ten minims into the 
enlarged gland. 

21 



GONORRHOEA. 

R-. Hydrarg. chlor. corros., gr. iij 
Sodii chloridi, gr. vj 

Aquae, 13 j. M. 

S. Add one teaspoonful of the mixture 
to one pint of hot water and flush urethra 
thoroughly one or two times a day. 
(Males.) 



fy. Hydrarg. chlor. corros., gr. xv 
Sodii chloridi, gr. xxx. 

Aquse, t'Sj. M. 

S. Add two teaspoonfuls of the mix- 
ture to two pints of hot water and flush 
vagina thoroughly three times a day. 
(Females.) 

IJ.. Hydrarg. chlor. corros., gr.^tol% 
Zinci sulpho-carbolat., gr. ij to x 
Acidi boric, 5j 

Hydrogen peroxide, fsj 
Aquae destil., q. s. ad. fSviij. M. 
S. Use as an injection from four to six 
times a day, immediately after urina- 
ting. (White.) 

IJ*. Zinci sulpho-carbolat., gr. vj 
Morph. sulph., gr. iij 

Aquae destil., fSiij. M. 

S. Use as an injection from four to six 
times a day, after urinating. 

R% Zinci sulphatis, 

Acidi tannici, aa gr. xv 

Aquae rosae, fSvj. M. 

S. A tablespoonful injected two or 

three times a day. (Ricord.) 



fy. Zinci chloridi, gr. j to ij 

Aquae destil., fgvj. M. 

S. Inject once or twice daily. 

(Levis.) 



R-. Zinci sulphatis, J5j 

Aluminis, giij. M. 

S. Dissolve a teaspoonful in one pint 
of water and inject three times a day. 
(Females.) (Hazard.) 

R-. Liq. plumbi subacetat. 
dil., fSj 

Ext. opii aquos., gr. vj. M. 

S. Use as an injection two to four 
times daily. (Van Buren and Keyes.) 

R. Zinci sulphat., gr. j to iij 

Liq. plumbi subacetat. 
dil., fgj. M. 

S. Shake and inject three to four times 
daily. (Van Buren and Keyes.) 



322 



SURGERY. 



R-. Potassii permanganatis, gr. j to iij 

Aquas destil., fSj. M. 

S. Use as an injection. (Gleet.) 

(Van Buren and Keyes.) 

R-. Argent, nitratis, 5j 

• Aquas destil., fjij. M. 

S. Apply thoroughly by means of a 
tubular speculum. (Females. 

(Grandin.) 



I* 


Salol, 


5j to ij 




Oleoresin. cubeb., aa 


Sj 




Para balsam copaib., 


3ij 




Pepsin, 


gr. xij 




Et ft. capsul. No. xxiv. 


M. 


s. 


Take two capsules six times a day 






(White.) 


% 


Liquor potasses, 
Balsam, copaibas, 


ftj 




fgss 




Tr. cubebas. 


f3vj 



Morphinse sulph., gr. ij 

Aquse camphoras, q. s. ad. f3vj. M. 
S. Take a tablespoonful four times a 
day. (Agnew.) 

ty. Potass, citratis, Sss to j 

Spts. limonis, fsss 

Syr. simplicis, fgij 

Aquse, fsj. M. 

S. A dessertspoonful, well diluted, 
three or four times a day. (In first 
stage.) (Van Buren and Keyes.) 

R-. Potass, citratis, 3ij to vj 

Balsam, copaibas, 3iij to vj 

Ext. hyoscyami li., f5ss to ij 

Syr. acacias, fsiss 

Aqua? menth.pip.,q.s.ad. fgiij. M. 
S. Take a teaspoonful in water three 
or four times a day. 

(Van Buren and Keyes.) 



S. 
day 



Balsam, copaibas, 
Spts. aeth. nitrosi, 
Liq. potassas, 
Ext. glycyrrhizas, 
M. et ad : 
01. gaultherias, 
Syr. acacias, 
One tablespoonful 



f5ij 



gtt. xvj 
fgyj. M. 
three times 
(Bumstead.) 



R-. Balsam, copaibas, 
Spts. astheris nitrosi, 
Spts.lavand. comp., aa fsss 
Liq. potassas, fsj 

Mucil. acacias, q. s. ad. f3iv. M. 
S. Shake and take one tablespoonful. 
(Lafayette mixture.) 

(Charity Hospital, N. Y.) 



H^EMATEMESIS. 

R. Liq. ferri subsulphatis, fSss. M. 
S. One to two drops in ice water, fre- 
quently. (Bartholow.) 

R-. Destillat. hamamelis, f3ij. M. 
S. Two to four drops every two or 
three hours. (Ringer.) 

$. Ergo tin., gr. xij 

Aquas destil., f3j. M. 

S. Five to ten minims hypodermically 
every two to four hours. (Wood.) 

R-. Plumbi acetatis, gr. xij 

Ext. opii, gr. iij. 

Ft. pil. No. vj. M. 

S. One pill every two or three hours 
until bleeding ceases. (Wood.) 

R\ Ext. ergot., 3j 

Ft. capsul. No. xij. M. 

S. One capsule every two hours. May 
give morphine or opium to quiet. 

(Wood.) 



ty. Acidi tannici, 5iij 

Aquas, fsj. M. 

S. Teaspoonful in water every half- 
hour until bleeding stops. 

Note. Do not give Monsel's solution 
and tannic acid to same patient, since 
it forms tannate of iron=Ink. 



HEMATURIA. 
R-. Aluminis, gr. xxiv 

Aquas, ?Sviij 

S. Inject into bladder only if hemor- 
rhage is alarming, since it forms clots 
which may become septic. (Hare.) 

R\ Acid, gallici, 5j 

Acid, sulphuric, dil., f5ij 
Aquas, q. s. ad. fgviij. M. 

S. Teaspoonful in water e^ery four 
hours. (Hare.) 

Ergot and other internal remedies 
same as bleeding from lungs, bowel, etc. 



R. Olei terebinthinas, f3x 

Magnesii sulph., 5j 

Pulv. uvas ursi, 5j 

Aquas camphoras, fSviij. M. 

S. Shake well. Take two tablespoon- 
fuls every two hours. (Smith.) 

HEMOPTYSIS. 

fy. Liq. ferri subsulphatis, 

gtt. xx to xxx 
Aquas destil., fgiv. M. 

S. Use in an atomizer every few min- 
utes. (Hare.) 



SURGERY. 



323 



R. Acidi tannici, gr. xx 

Glycerinae, foij 

Aquae destil., q. s. ad. fgviij. M. 
S. Use in atomizer frequently. 

(Hare.) 
Avoid using Monsel's solution and 
tannic acid on same patient=Ink. 

R. Aluminis, gr. vj 

Aquae destil., fSiij. M. 

S. Use in an anatomizer frequently. 
(Hare.) 

R. Plumbi acetat., gr. xx 

Pulv. digitalis, gr. x 

Pulv. opii, gr. v 

Ft. pil. No. x. M. 

S. One pill everv four hours. 

(Bartholow.) 
Use opium or morphine to quiet pa- 
tient. 

HEMORRHOIDS. 
R. Acidi gallici, gr. x 

Ext. opii, 

Ext. belladonna?, aa gr. iv 
Ung. simplicis, 5iv. M. 

S. Apply night and morning. 

(Hare.) 

R. Ext. hamamelis fl., fsiv. M. 

S. Inject some into the rectum and 
apply pledgets of lint soaked in this 
solution. (Hare.) 

R. Cocain. hydrochlor., gr. ij 
Ext. belladonna?, 5j 

Acidi tannici, 5ij 

Ung. petrolati, 5j. M. 

S. Apply night and morning. 

(Alrich.) 

R. Ext. opii, gr. x 

Pulv. stramonii, 5j 

Pulv. tabaci, 5ss 

Ung. simplicis, Sss. M. 

S. Use locally. (Shoemaker.) 

R. Iodoform., Sij to iv 

Adipis benzoat., gj. M. 

S. Apply locally after washing. 

R. Tr. nucis vomicae, f5j 

Ext. ergot, fl., fgj. M. 

S. One teaspoonful three to four times j 
a day. (For bleeding piles.) 

(Bartholow.) 

INCONTINENCE OF URINE. 

R. Strychninae sulph., gr.j 

Pulv. cantharidis, gr. ij 

Morph. sulph., gr. iss 

Ferri redacti, gr. xx. ]\ 
Ft. pil. No. xl. 
S. One pill three times a day to 

child ten years old. (Gross.) 



R. Chloral hydratis, 5j 

Syr. tolutani, fgiiss. M. 

S. One teaspoonful three times daily. 
(For infantile incontinence.) 

(Da Costa.) 

R. Santonini, gr. xyj 

01. ricini, fgj. M. 

S. One to two teaspoon fuls before 
breakfast for two or three mornings. 
(Ringer.) 

R. Acidi arsenosi, gr. y ? 

Ext. nucis vomicae, gr. ij 

Ft. pil. No. xx. M. 

S. One pill three times a day after 
meals. (For a child eight to ten years 
old, when trouble is due to weakness of 
spinal centres.) (Hare.) 

R. Potass, citrat., Sss 

Spts. aeth. nit., f5vi 

Aquae, q. s. ad. fgvj. M. 

S. A dessertspoonful every four hours 
in water. (Where urine is concentrated 
and dark in color.) (Hare.) 

R. Tr. cantharidis, f3j. M. 

S. One drop three times a day. (In 
hysterical females.) (Hare.) 



INFLAMMATION. 
Fever Mixtures. 
R. Potass, bromid., 3iv 

Tr. belladonna?, "flxxxij 

Tr. aconit. rad., gtt. viij 

Spts. aeth. nit., foiij 

Mist, potass, cit., q. s. ad. fgviij. M. 
S. One tablespoonful every two to 
three hours. Keep in a cool place. 
(White.) 

R. Morph. acetat., gr. j 

Sacchar. alb., Sij 

Spts. aeth. nit., f5ij 

Liq. ammonii acet., fgiv 
Aquae camphorae,q.s. ad. fgviij. M. 

S. One tablespoonful every two to 
three hours. (Ashhurst.) 

R. Morph. acetat., gr. % 

Tr. aconit., *2x ' 

Spts. aeth. nit., f5iij 

Mist, potass, cit., q. s. ad. fgvj. M. 

8. Two teaspoonfuls every one to two 
hours. 

Laxatives. 

R. Hydrarg. chlor. mit., gr. iij 
Sodii bicarb., 5j 

Ft. pulv. No. xxiv. M 

S. One powder every hour. 



324 



SURGERY. 



R. Hydrarg. chlor. mit., gr. iv 
Sodii bicarb., 5j 

Pepsina?, 5ss M. 

Ft. pulv. No. xxiv. 

S. One powder every hour. 

Add 5ij of Rochelle salts to the white 
paper of a Seidlitz powder, take it and 
follow it every two hours by 5ij of Ro- 
chelle salts until bowels move. 

(Goodell.) 

R. Syr. rhei aroniat., fSss 

Aquae, fSij 

Magnesii sulph., q. s. ad. sat. sol. M. 
S. A teaspoon ful every hour or two 
until bowels move. 



R. Hydrarg. chlor. mit., gr. j 
Sacch. lactis, 5j M. 

Ft. pulv. No. xij. 

S. One powder every one to three 
hours. (For children.) 

R. Pulv. glycyrrhiza? comp. , gss. M. 
S. One teaspoon ful in water. Repeat 
every two hours if necessary. 



INGROWING NAIL. 

R. Liquor potassse, fsij 

Aqua? destil., fgj. M. 

S. Apply with pledgets of cotton. 

(Norton.) 

R. Pulv. plumbi acetat., 5j 
Tr. opii, fsj 

Aqua?, fgviij. M. 

S. Shake well, and apply constantly 
on cotton until inflammation is re- 
duced; then separate nail from gran- 
ulating surface by means of a small 
pledget of cotton and use 
R. Argent, nitratis, gr. xxx 

Aqua? destil., fsj. M. 

S. Paint two or three times daily. 
(Davidson.) 



LARYNGISMUS STRIDULUS. 



Potassii citratis, 


5j 


Syr. ipecac, 


f3ij 


Tr. opii deod., 


gtt. xij 
?3ij 


Syr. simplicis, 


Aquse, 


fSiss. M 



S. A teaspoon ful every two hours at 
two years of age. (In severe form.) 
(Meigs and Pepper.) 

R, Syrupi ipecacuanha?, fsij. M. 
£. A teaspoonful every fifteen minutes. 



R. Amyl. nitrit., f3j. M. 

S. Three to five drops on a handker- 
chief by inhalation. (Wood.) 



R. Tr. belladonna?, f3j. M. 

S. Five to fifteen drops every hour, 
according to age. (Hare.) 



LEUC0RRHO2A. 

R. Aluminis, Siv. M. 

S. Add to one pint of warm water and 
use as a wash morning and evening. 



gr.J 
gr. vj. 



M. 



R. Ext. belladonna?, 
Acidi tannici. 
Ft. pulv. No. j. 
S. Place on a pledget of cotton and 
apply to diseased portions daily. 
(When dependent on disease of cervix.) 
(Troscall.) 



R. Acid, arseniosi, 

Ferri redact., 

Quin. sulph., 

Ft. pill. No. xx. 
S. One pill after each meal, for adult. 
(Hare.) 



gr. ij 

gr. xx M. 



R. Tr. ferri chloridi, f5.j 

Tr. cinch, comp., fsij 

Tr. gent, comp., q. s. ad. fsiv. M. 

S. One dessertspoonful after meals. 
(Hare.) 

R. Iodi resublimat, 5iv 

Acid, carboliei crystal., 
Cblorali, aa gj. M. 

S. Rub the iodine and chloral in a 
glass mortar and add the carbolic acid. 
To be used by the physician only. Vagi- 
nal surfaces and cervix to be painted 
with it. (Goodell.) 

R. Sodii bicarb., 5j 

Tr. belladonna?, f3ij 

Aqua?, Oj. M. 

S. Use as a vaginal wash morning and 
evening. (Ringer.) 



R. Potassii permanganat., 5ij 

Ft. pulv. No. iv. M. 

S. Add to a pint of warm water and 
inject morning and evening. (When 
discharge is fetid.) (Girwood.) 

R. Zinci sulphat., fSj 

Alumin. sulph., 3j 

Glycerina?, fSvj. M. 

S. Add a teaspoonful to a quart of 
water and inject twice a day. 

(Thomas.) 



SURGERY. 



325 



ty. Acidi tannic! , giv 

Glycerins;, fSxvj. M. 

S. Add a tablespoon ful to a quart of 

tepid water and inject into vagina for 

five minutes morning and evening by 

means of a fountain syringe. 

(Thomas.) 

ft. Sodii biboratis, 5ij. M. 

S. A teaspoonful to a pint of tepid 
water as a vaginal wash. (For leucor- 
rhoea of pregnancy.) (Parvin.) 

R-. Iodoformi, 5j 

Acidi tannici, 5j. M. 

S. Pack a sufficient quantity around 
the cervix. (Bartholow.) 

LUMBAGO. 

1^. Atropinae sulphatis, gr. j 
Morphinse sulphatis, gr. xvj 
Aqua? destil., fsj. M. 

S. Five minims injected deeply into 
muscles of the back. ' 

R. Antipyrin, 3j 

Syr. tolutani, fgj 

Aq. menth. pip., q. s. ad. fgiv. M. 
S. A teaspoonful every one to four 
hours for three to six doses. 

(Germain See.) 

R. Methyl chloride, gss. M. 

S. Use locally, applying carefully. 
(Debove.) 

R. Tr. iodi, fsij 

Tr. aconiti rad., f3iij 

chloroformi, f3iv 

Liniment, sapon. comp., 

q. s. ad. fgiij. M. 
S. Apply every few hours locally. 

(Bellevue Hospital, N. Y.) 



R. Potass, iodidi, 5ss 

Tr. opii deodorat., f3ij 

Spts. lavandulse comp., f3j 
Spts. geth. nit., fgss 

Aquae destil., fgxij. M. 

S. Take two tablespoon fuls twice daily. 
(Brodie.) 

R. Potass, iodidi, 

Potass, carbonatis, iia. 3j 
Tr. aconiti rad., fgij 

Aquae destil., fSx. M. 

S. Apply locally every few hours. 

(Erichsen.) 

R. Chloroformi, fsij. M. 

S. Twenty minims injected deeply in 
region of pain 



LUPUS. 

R. Zinci chloridi, 5j 

Morph. sulph., gr. ss 

Pulv. acac, 5iij. M. 

S. Make into a paste by adding a kw 
drops of water or alcohol and spread a 
thin layer over and just beyond the 
ulcer. Use carefully. (Agnew.) 

R. Ichthyol., 5j 

Adipis benzoat., 3v. M. 

S. Apply over affected part. (Hare.) 

R. Tr. iodi, f3ij. M. 

S. Paint around the growth ; apply to 
retard its spread over the surface also. 



R. Liquor hydrargyri nit., f5j. M. 

S. Use with a glass rod until growth 
is on a level with the skin ; use care- 
fully, protecting surrounding parts with 
lard or oil. 



R. Acidi pyrogallici, 5j 

Oerati simplicis, 3ix. M. 

S. Apply locally. (For lupus of eye- 
lids and skin.) (Kaposi.) 

Apply locally a saturated solution of 
muriate of cocaine. (Fowler.) 



R. Resorcin, 
Vaselini, 
S. Apply locally. 



3iiss 
5iv. M. 
(Bertarelli.) 



MAMMARY INFLAMMATION. 

R. Morph. sulph., gr. x 

Hydrarg. oleat., 5ss 

Acidi oleici, Sixss. M. 

S. Anoint three times a day. 

(Marshall.) 

IJ.. Ext. belladonna?, 3j 

Liq. plumbi subacetat. 
dil., Oj. M. 

S. Use as a lotion. (Graefe.) 



S. A tablespoon ful of granular effer- 
vescent citrate of magnesia in water, 
followed by ten grains of quinine if 
there be fever. (In incipient mammi- 
tis.) (Starr.) 



R. Cerati resinse co., 3j 

Olei oliva?, 5j to ij M. 

Ft. ungt. 
S. Apply, spread generously on a soft 
rag. (When suppuration is threatened.) 
(Witherstine.) 



326 



SURGERY. 



NEURALGIA. 
R. Ext. aeonit., gr. ij 

Adipis benzoat., 5j. M. 

S. Apply over painful parts if limited 
in area. 

Rhigolene or ether in an atomizer is 
often effectual if pain is superficial. 

R. Antipyrin., 5j 

Caffein. citrat., gs. xx. M. 

Ft. chart. No. x. 

S. One every thirty minutes until re- 
lieved. Or, 

IJ.. Antipyrin., 5j 

Caffein. citrat., gr. x 

Potass, bromid., 3iij. M. 

Ft. chart. No. x. 

S. One every thirty minutes until re- 
lieved. (Hare.) 

Sometimes acupuncture is useful or 
deep hypodermic injections of morph. 
sulph. 

R. Tr. cannabis indicas, fgij. M. 
S. Twenty drops every hour. (Mi- 
graine.) (Wood.) 

R. Methyl, chlorid. pur., fgj. M. 
S. Apply to painful parts with a brush 
or atomizer. 

R. Chloroformi, f5j 

Vaselin. liq., f3iv. M. 

S. Fifteen to thirty minims hypoder- 
mically at seat of pain. (Meunier.) 

R. Menthol., gr. xxiis 
Cocain. muriatis, gr. viiss 
Chloral, hydratis, gr. ivss 
Vaselin., 3iiss. M. 
S. Apply to painful part and cover 
with strip of court plaster. (Supra- 
orbital neuralgia.) (Galezowski.) 



R. Quin. sulph., 
Morph. sulph., 


5j 




Acidi arseniosi, aa 


gr. iss 


Ext. aconiti, 


gr. xv 


Strych. sulph., 


gr. j. M. 


Ft. pil. No. xxx. 




S. One pill three times 


i day. 




(Gross.) 


R. Phenacetin., 


gr. xj. M. 


Ft. pulveres No. x. 




S. One or two powders 


every three or 


four hours. 





Place a small pledget of cotton soaked 
in chloroform over painful spot and 
confine fumes by covering with a small 
glass or a pill-box. 



ONYCHIA. 
R. Pulv. plumbi nitrat., gss. M. 
S. Dust on diseased tissue night and 
morning. (Scott and McCormack.) 

In the early stages a couple of leeches 
above the nail will have a good effect. 
(Agnew.) 

Use hot flaxseed poultices for three or 
four days, before each renewal of the 
poultice, thoroughlv washing with— 
R. Tr. iodi, 

Tr. belladonnas, 

Tr. opii, aa f5ij. M. 

Then dust with iodoform and dress 
antiseptically. (Agnew.) 



R. Acidi arseniosi, 
Glycerol, amyli, 
S. Apply on a soft rag. 



Sj. M. 

(Agnew.) 



R. Ung. hydrargyri, gss. M. 

S. Apply for ten minutes every hour, 
applying poultices at other times. 

(Ringer.) 

R. 01. terebinthinas, fgij. M. 

S. Apply a pledget of lint wet with 
the solution. (Ringer.) 

ORCHITIS. 
Keep the testicles elevated. 

Strap with adhesive strips. 

First envelop scrotum in thick layer 
of cotton ; over this rubber dam ; then 
use an ordinary suspensory that is close 
fitting. (Horand-Langlebert.) 

R. Iodi, gr. iv 

Lanolin, gj. M. 

S. Apply locally (after acute symptoms 
are past). 

R. Ung. hydrarg., 

Ung. belladonnas, aa gss. M. 
S. Apply locally morning and even- 
ing. 

R. Potass, iodidi, 5iv to viij 

Syr. sarsaparillas comp., fgiij 
Aquas, q. s. ad. fgvj. M. 

S. Two teaspoonfuls three times a day. 



R. Tr. iodi, fsij. M. 

S. Paint affected parts after acute 
rmptoms are over. 



SURGERY. 



327 



1$.. Morphinse sulphatis, gr. viij 
Hydrargyri oleatis (10 
per cent.), 5j. M. 

S. Apply twice daily. (For subsequent 
induration.) (Marshall.) 

PROSTATITIS. 

Leeches to the perineum. 



gr. viij 
gr. ij. M. 



R. Ext. opii aquos., 
Ext. belladonna;, 
Ft. suppos. No. viij. 
S. Introduce one into the rectum and 
repeat on return of pain. 



Very hot or very cold water injected 
into the rectum, against the prostate 
through a two-way rectal tube, from 
two to four quarts at a time, three or 
four times a day. 

I}.. Ext. opii aquos., gr. viij 

Ext. hyoscyami, gr. iv. M. 

Ft. suppos. No. viij. 

S. Insert one into the rectum and re- 
peat when necessary. 

R. Liq. potassse, foij to iv 

Ext. hyoscyami, 3j to iv 

Syr. aurant. cort., 
Aquse cinnamomis, aa fSiij. M. 
S. A tablespoonful in a wineglass of 
water every eight hours. 

(Van Buren and Keyes.) 

R. Potass, bicarbonat., 5iv 

Ext. hyoscyami fl., f5ij 

Syrupi simp., fsij 

Aquse, q. s. ad. fSvj. M. 

S. A dessertspoonful every two to four 
hours. 



PRURITUS. 
1$.. Acid, carbolici, f5j to f5ij 

Aquse destil., q. s. ad. Oj. M. 
S. Apply as a lotion several times a 
day. 

R. Liq. carbonis deterg., fgij 

Aquse, q. s. ad. Oj. M. 

S. Apply as a lotion. 



R. Acidi carbolic, 
Adipis benzoin., 
Ung. petrol., aa 

S. Apply as an ointment. 

R. Chloroformi, 

Adipis benzoin., 
S. Apply as an ointment. 



gtt. v to xx 

3j- 



M. 



"5x to xx 
Sij. M. 



R. Argent, nitratis gr. xx 

Aquse destil., fsj. M. 

S. Paint affected parts (in obstinate 
cases). 

fy. Hydrarg. chlor. eorros., gr. j 
Pulv. aluminis, 9j 

Pulv. amyli, 5iss 

Aquse, f5vj. M. 

S. Apply locally. (Goodell.) 

R. Aluminii nitratis, gr. vj 

Aquse destil., f3j. M. 

S. Apply with a soft sponge. (Gill.) 



R. Acidi acetici, 

Glycerinse, 
S. Apply locally. 



fsj 

fSiij. M. 
(Goodell.) 



RACHITIS— SCROFULA. 
R. Olei morrhuae, f3vj 

Syr. calcii lactophosphat., 
Liq. calcis, aa fSiij. M. 

S. One-half to one teaspoonful three 
or four times a day. (Smith.) 



R. Syr. ferri iodidi, gtt. iij to xx 

Aquse destil., q. s. ad. fsiij. M. 

S. A teaspoonful every four or live 
hours during the day. (Child six 
months or one year.) 

R. Syr. calcii lactophos., fsiv. M. 
S. One teaspoonful three times a day 
after meals. 

R. Phosphor i, gr. ~% 

Olei amygdalse, i3viiss 
Pulv. acac, 

Sacchar. alb., aa 5iv 

Aquse destil., f3x. M. 
Ft. emuls. 

S. One teaspoonful three times a day 

after meals. (Hare.) 

R. Phosphor i, gr. % 

Olei morrhuse, isyj. M. 

S. One teaspoonful three times a day 
after meals. (Kassowitz.) 

R. Calcii phosphatis, 

Ferri phosphatis, aa gr. xxxvj. M- 

Ft. chart. No. xij. 
S. One powder morning and noon. 

(Neligan.) 

R. 01. morrhuse, fsiv 

Aquse calcis, fsiij. M. 

Et ad. 

Syr. ferri iodidi, f3iv 

01. gaultherise, foss 

Syr. simp., q. s. ad. fSviij. M. 

S. A tablespoonful three times a day. 



328 



SURGERY. 



SCIATTCA. 
Acupuncture. 

Deeply inject hypodermically, just 
over or about the exit of the nerve 
from the pelvis, ten to twenty minims 
of chloroform. 

Ether or rhigolene spray. 

Blisters or actual cautery along the 
course of the nerve. 

Massage of nerve. Apply lard or ich- 
thyol ointment along the course of the 
nerve ; then take a strong glass rod with 
a round, smooth end, press back and 
forth over the tender area, using as 
much force as can be borne. (Hare.) 

R. Morph. sulph., gr.>2 to % 

Atrop. sulph., gr. 1-25. M. 

Ft. pulv. No. j. 

S. Dissolve in ifyxx aq. destil. and 

inject near focus of pain. (Brown- 
Sequard.) 

R. Cannabis indicae, f5yj 

Syr. acaciae, f5iss 

Aquae destil., q. s. ad. fSyj. M. 

S. A tablespoonful every four to six 
hours. (Neligan.) 



SEPTICEMIA. 
Stimulants should be pressed to their 
extreme limit. 

Tonics, if the stomach will stand them. 
Quinine, twenty to thirty grains daily. 
Digitalis as indicated by the condition 
of the heart. Strychnia for the respi- 
ration. 



SHOCK. 
External warmth most important; 
a hot bath, or vessels of hot water all 
around patient. Keep the head low. 

Atropine, 1-100 gr. and brandy or 
whiskey, minims xxx, hypodermically 
every thirty minutes. Digitalis hypo- 
dermically, in minims-xx doses, may 
be indicated. If there is great paiii, 
give a hypodermic of morph., % to % 
gr. ; strychnia hypodermically, gr. 1-20, 
repeated at twenty-minute interval^ 

Whiskey, hot coffee, or hot beef-tea in 
very small quantities by the mouth. 



SPERMATORRHCE A . 

R-. Potass, brom., 

Sod. brom., ail 5iv 

Aq. cinnamom., q. s. ad. fSxij. M. 

S. One tablespoonful at bedtime. 



I*. Chloral., 

Syrupi simplicis 



5ij 

fSiss 



Aquae, q. s ad. fSiij. M. 

S. One tablespoonful at bedtime. 



R-. Hyoscinehydrobromate,gr. 1-10. 

Ft. pil. No. x. M. 

S. One pill at bedtime. (Wood.) 



ty. Tr. cantharidis, f5ij 

Tr. ferri chloridi, fgvj. M. 

S. Twentv drops in water three times 
day. (Wood.) 

R-. Acid, arsenios., 

Strych. sulph., aa gr. % 
Ferri redact., 5ss. ' M. 

Ft. pil. No. xij. 

S. One pill three times a day. 



I£. Argent, nit., gr. xx 

Aquae destil., isiv. M. 

S. Apply three drops to the prostatic 
urethra. 



A full-sized cold-steel sound intro- 
duced into the bladder is often of ser- 
vice. 



SPINA BIFIDA. 
R-. Iodi, gr. x 

Potass, iodidi, gr. xxx 

Glycerinae, fsj. M. 

S. Inject into the base of the tumor, 
according to its size, from 5ij to Siv of 
this solution. (Morton.) 

SPRAINS, CONTUSIONS, ETC. 



ty. Olei monardae, 

Tr. opii, 

Tr. camphorae, 

Ft. liniment. 
S. Use locally. 

R\ Olei cajuputi, 

Tr. opii, aa 

01. terebinthinae, 
Linimenti ammoniae, 
Ft. linimentum. 

S. Use locally. 



fSss 
f3ij 
f5ij. 



M. 



(Atlee.) 



f5ij 
f5iv 
fSj. M. 

(Fuller.) 



SURGERY. 



329 



J?.. Liquor ammonise, f3j 

Tr. opii, fjij 

Tr. cantharidis, f3iij 

Lii)imeii.sapon.caniph.,f3x. M". 
Ft. liniment u in. 

S. Use locally. (Fuller.) 

R. Chloroform i, 
Tr. aeon it. rad., 
Ol. terebinth in*, aa fjss 
Ol. sassafras., ttyv 

Linimen.sapon.camph.,f3iiss. M. 
Ft. linimentuni. 

S. Use locally. (Gerhard.) 

R. Tr. aconiti, 

Chloroformi, 

Aquae ammonia?, aa f5ij 

Linimen. saponis camph., 

q. s. ad. fSviij. M. 

Ft. linimeutum. 
S. Use locally. (Jefferson Hospital.) 



R. Tr. aconit. rad., 
Tr. opii, 
Lin. saponis, 
Ft. linimentuni. 

S. Use locally. ' 



m 

i'Sss 
fSviss. M. 

[Richardson.) 



R. Plumhi acetat., 5j 

Tr. opii, f5ix 

Aqua?, q. s. ad. f3vj. 

S. " Lead water and laudanum." 
locally. 



M. 

Use 



Any of the officinal liniments may he 
used alone. 

Linimentuni caniphorse. 
Linimentum chloroformi. 
Linimentum saponis. 
Linimentum terebinthinse. 



STRANGURY. 

R. Decoct. uvee ursi, f3viij 
Liq. potassa?, gtt. exxx 

Tr. belladonna?. gtt. xlviij. M. 

S. Tablespoon ful every four hours. 
(Agnew.) 

R. Balsam, copaibse, 3ss 

Acidi benzoici, 5j 

Vitelli unius ovi, 
Aqua? camphorse, fSvij. M. 

S. Take two tablespoon fuls twice a 
day. (Soden.) 

R\ Aceti scillse, 

Spts. a?th. nitrosi, aa foij 
Aquse anisi, q. s. ad. Oj. M. 

S. A wineglassful every hour or oft- 
ener. (Waring.) 



R. Ext. opii, gr. iv 

Ext. hyoscyaini, gr. ij. M. 

Ft. suppos. No. iv. 

S. Introduce one into the rectum. 



R-. Tr. cannabis indicse, fsij. M. 
S. Thirty drops every few hours. 

(Ringer.) 

R. Ext, belladonna?, gr. ijtoiv. M. 

Ft. suppos. No. ij. 
S. Introduce one into rectum and re- 
peat in four hours if necessary. 

(Hartshorn e.) 

Hot sitz bath for one-half to two 
hours. 



SYNOVITIS. 
Counter-irritation by means of fly 
blisters. 

Blood-letting in early stage, followed 
by ice-bags. 

R. Acidi carbolici, gr. viij 

Aqua? destil., fsj. M. 

S. Use ether spray, and inject ten min- 
ims into joint and repeat every three 
days. (Chronic synovitis.) 

R. Morph. sulph., gr. viij 

Hydrarg. oleat. (5 to 10 
per cent.), 3j. M. 

S. Apply twice daily with a soft brush. 
(Acute synovitis.) (Marshall.) 

Paint joint with tr. iodine and apply 
R. Ung. hydrarg., 

Ung. belladonna?, aa 3j. M. 
S. Apply on lint. (Ashhurst.) 

R. Iodi, 5iv 

Potass, iodidi, f3j 

Aquae destil., fSvj. M. 

S. Apply externally with a brush. 



SYPHILIS. 
R. Hydrarg. protiodidi, gr. vj. M. 

Ft. pil. No. xxiv. 
S. One pill three times a day ; every 
second day increase by one pill until 
first symptoms of ptyalism appear; 
then cut down dose one-half and con- 
tinue for eighteen months this tonic 
dose; after that give 
R. Potass, iodidi, Sisstogiv 

Hydrarg. chlor. corros., gr. i to iss 
Syr. auranti cort,, fsj 

Aquse, q. s. ad. fSij. M. 

S. One teaspoonful three times a day 
continued for from six to twelve months 



330 



StfRGERY. 



R. Mass. hydrarg., gr. xxiv 

Pulv. ferri sesquichlor., gr. xij. M. 
Ft. pil. No. xij. 
S. One pill three times a day ; increase 
one pill evei'y two days up to physio- 
logical limit; then cut down dose one- 
half and continue for eighteen months. 

R. Ung. hydrarg., gj. M. 

Ft. chart. No. viij. 
Put in waxed papers. 

S. Rub, after bathing, for fifteen min- 
utes the contents of one paper into 
body in following order: First night, 
axilla and side of chest; next night, 
same on opposite side; next night, 
groin and inner part of thigh ; next, 
same on opposite side; next, chest and 
abdomen, and repeat. Wear same shirt 
next to skin under other clothing. 

Mucous patches in mouth are healed 
by application of solid stick of silver or 
sulphate of copper. If elsewhere, wash 
with 1-2000 bichloride solution and dust 
with 

R. Hydrarg. chlor. mit., 

Bismuth, subnit., aa 5ij. M. 

S. Dusting powder. 

After symptoms disappear, observe 
hygienic mode of living and take 
R. 01. morrhuse, fSviij. 

(Phillips's emulsion.) 
S. One teaspoonful three times a day. 

The mercury may be given by means 
of vapor bath. 

R. Hydrarg. chlor. mit., gss. 
S. Vaporize by means of heat, beneath 
a blanket covering the naked body. 

R. Hydrarg. chlor. corros., gr. vj 
Sodii chlorid., gr. xxxvj 

Aquae destil., ?3x. M. 

S. Inject daily five to eight drops 
hypodermically. (Hebra.) 

R. Pil. hydrargyri, gr. xx 

Ferri sulph. exsiccat., gr. x 
Ext. opii, gr. v. M. 

Ft. pil. No. xx. 

S. One pill three times a day. 

(Otis.) 

B- Potass, iodidi, 5ij 

Ammonii carbonatis, gss 

Tr. cinch, comp., f3iv 

Syr. aurant. cort., f3iss 

Glycerini., fij. M. 

S. A teaspoonful, well diluted, after 

each meal. (Keyes.) 



B. Tr. myrrh., fsss 

Potass, chlorat., 5iij 

Aquae, q.s. ad. fgvj. M. 

S. Wash mouth every two or three 
hours. (For mucous patches.) 



R. Hydrarg. chlor. corros., gr. j 
Potass, iodidi, 5ij 

Tr. gent, comp., fsiij. M. 

S. A teaspoonful three times a day. 
(Charitv Hospital, N. V.) 



B. Hydrarg. chlor. mit., 

Lycopodii, aa 5ij. M. 

S. Use as snuff three times daily, in 
syphilitic lesions of nose. (Gross.) 

TETANUS. 

Control the spasm by inhalations of 
ether, chloroform, or nitrite of amyl. 
Give 5ij to 5iv of bromide of potash in 
divided doses during the day, and 
chloral, gr. xxx to xl at bedtime. 

Also give opium, if necessary. Sup- 
port with food and stimulants. 

(Wood.) 

WARTS AND CORNS— COMMON. 

B- Acidi nitrici, fgj. 

S. Apply to wart with a stick or glass 
rod three or four times a week. 



R. Acidi chromici, 5j. M. 

S. Apply to wart with a glass rod. 
(Wood.) 

B- Hydrarg. chlor. corros., gr. x 

f5v. M. 



Collodii 
S. Paint once daily 



(Kaposi.) 



R. Acidi salieylici, 

Spts. vini rectif., aa fsss 
iEtheris sulphuric, "5lxxv 
Collodii, f3iiss. M. 

S. Apply every day with camel's-hair 
brush. (Vidal.) 

B- Acidi acetici glacialis, f3j. M. 
S. Apply a drop to wart once a day. 

B- Acidi salieylici, gr. xxx 

Ext. cannabis indicse, gr. x. M. 
Collodii, fsss. M. 

S. Apply every night and morning 
for one week with a camel's-hair brush; 
then soak foot well. 



Moisten and brush every day with 
solid stick of nitrate of silver. 



SURGERY. 



331 



WARTS— VENEREAL. 

R. Hydrarg. ehlor. in it. 

S. Use as a dusting powder. 

(Ricord.) 

R. Acidi carbolici, f5j. M. 

S. Apply with glass rod or stick every 
day or two. 



R. Hydrarg. chlor. mit., 5vj 
Acidi borici, 3i ij 

Acidi salicylici, 5j. M. 

S. Dust over the vegetation. 

(< rregory.) 

Cut off with scissors and apply nitric 
or carbolic acid to base with a small 
stick. 



332 



SURGERY. 



DRUGS AND MATERIALS USED IN ANTISEPTIC SURGERY, 



TOGETHER WITH 



GENERAL DIRECTIONS CONCERNING PREPARATIONS FOR 
ANTISEPTIC OPERATIONS. 



ANTISEPTIC SOLUTIONS. 
R. Acid, carbolic, f5vj% 

Aquae, q. s. ad. Oj. M. 

S. Solution 1-20 carbolic. (Lister.) 

ft. Acidi boric, 5iv 

Aquae destil., Oj. M. 

S. Saturated solution, gr. x to fsj. 

ft. Potassii permanganat., 5j 

Aquae, fsj. M. 

S. f3j to Oj=l-1000. 

ft. Zinci cblorid., gr. xl 

Aquae, q. s. ad. fsj. M. 

S. Apply on a swab to fresh septic 
rounds. 



R. Hydrarg. chlor. corros., 
Sodii chlor., aa 5j 

Aquae, q. s. ad. fsj. M. 

S. f3j to Oj=l to 1000. 



ft. Hydrarg. chlor. corros., 3j 

Amnion, chlor., gr. xxxij 

Aquae, q. s. ad. fsj. M. 

S. f5j to Oj water=l to 1000 solution. 



ft. Hydrarg. chlor. corros., 5j 
Acid, tartaric, 5v 

Aquae, q. s. ad. fsiv. M. 

S. fi% to Oj aquae=1000. 



R. Acidi carbolic, 

01. olivae, 
S. Carbolized oil. 



f5j 

f5x. M. 
(Lister.) 



ft. Iodoform., 3j 

Collodion., f3x. M. 
S. Iodoform collodion. (Kiister.) 

ft. Iodoform., gr. xxx 

iEther fsss 

Aquae destil., q. s. ad. fsj. M. 

S. Iodoform ether. (Nussbaum.) 



R. Iodoform., 

^Ether^ 
S. Iodoform ether. 

ft. Creolin, 

S. f5j to f5vj to Oj. 



fsj. 

(v. Esmarch.) 



R. Hydrogen peroxide, fsj. 
S. Use in hard-rubber atomizer. 



SALVES. 

R. Acidi boric, Siij 

Paraffine, 3x 

Ung. petrol at., 5 v. M. 

S. Boric acid salve. (Lister.) 



R. Acidi salicylic, 5j 

Paraffine, 3xij 

Cerat. alb., 5vj 

01. amyg., 5xij. M. 

S. Salicylic salve. (Lister.) 

R. Iodoform i, 3j 

Ung. petrolati, 5vj 

01. amyg. amar., gtt. ij. M 

S. Iodoform salve. 

ft. Iodoform., Sj to iv 

Ung. petrolat., Sj. M. 
S. Iodoform ointment. 



SURGERY. 



333 



I*. 01. olivae, fSj 

Acidi carbolic, gr. xlj to xxiv. M. 
S. 1-40 or 1-20 carbolized oil. 



R-. Ung. petrolati, 5j 

Acidi carbolic, gr. xxiv to xij. M. 
S. 1-20 or 1-40 carbolized vaseline. 



LIGATURES. 

Immerse the commercial catgut in a 
frequently renewed solution made as 
follows : — 
R. Hydrarg. cblor. corros., 5j 
Alcohol, fSiiss 

Aquae destil., fSvj. M. 

Preserve for use in the following: — 
R-. Hydrarg. chlor. corros., gr. vj 
Alcohol, ftx 

Aquae destil., fjiiss. M. 

From this solution it is taken as 
needed. 



TO CHROMACIZE CATGUT. 

Place catgut in ether for forty-eight 
hours; then immerse in the following 
for forty-eight hours and put in anti- 
septic, dry, tightly-closed vessels : — 
I}.. Acidi chromic, gr.j 

Acidi carbolic, gr. cc 

Alcohol, foij 

Aquae destil., f3xxij. M. 

Soak in carbolic, 1-20 before using. 

The catgut is usually prepared by 
soaking it in oil of juniper for one 
week, then storing it in absolute alco- 
hol, or a 1-1000 alcoholic sublimate solu- 
tion. 



SILK (Czerny). 

The silk should be boiled for one hour 
in a 1 to 20 carbolic solution, then kept 
in a 1 to 50 carbolic solution. 



Boil in clean water for one hour, then 
store in an alcoholic solution of subli- 
mate 1-1000. 



DRAINAGE 

Rubber tubes, wash clean and keep in 
a 1 to 20 carbolic solution. 



Rubber tubing may be hardened by 
immersing for five minutes in concen- 
trated sulphuric acid. The tubes are 
then washed in alcohol and preserved 
in 1-20 carbolic solution. 



Decalcified bones, catgut, horse-hair, 
silk-worm gut, may all be stored in 
absolute alcohol containing sublimate 
1-1000. 

OPERATOR'S HANDS. 
Pare nails and clean around and under 
them with a knife. Clean arms, hands, 
and nails for one minute with a brush, 
very warm water, and potash soap (pear- 
line) ; then wash for one minute in 
stronger alcohol and then for one 
minute in 1-1000 or 1-500 bichloride- so- 
lution or 1-30 carbolic solution. The 
hands are then allowed to remain wet. 



OPERATIVE REGION. 
The patient should have a warm bath 
before the operation, and the operation 
region must be shaved and covered with 
cloths dipped in 1-1000 bichloride or 
1-30 carbolic, and covered with par- 
affine paper; this dressing must remain 
for several hours previous to the opera- 
tion. Immediately before the operation 
the parts are washed and brushed with 
potash soap, then rubbed with alco- 
hol, ether or turpentine, and irrigated 
with 1-500 bichloride or 1-30 carbolic 
solution. The environs should be cov- 
ered with towels wet with 1-500 bichlo- 
ride or 1-30 carbolic, and changed 
during the operation as often as soiled. 
The region to be operated upon should 
also be covered with similar towels 
until the surgeon commences his in- 
cision, and during the entire operation 
scrupulous care must be exercised to 
keep every portion of the wound cov- 
ered except that part which the surgeon 
must have exposed for the continuance 
of his work. 



INSTRUMENTS. 
Brush with 1-20 carbolic solution; 
sterilize by roasting, boiling, or by 
storing for one hour in 1-20 carbolic 
solution. During operation keep in a 
1-40 carbolic solution. To prevent rust- 
ing boil in one per cent. sod. carb. solu- 
tion. 

A very effectual method is to place 
them in metal boxes and heat in an or- 
dinary oven (200° F.) for one^-half to one 
hour ; they may then be used dry. 

SPONGES. 

If new, cleanse in soda solution and 
immerse for twenty-four hours in water 
to which is added 

IJ.. Potassii permanganat., gr. 15%. 



334 



SURGERY. 



This turns thein brown ; then wash in 
a bowl of water, to which add 
fy. Acid, hydrochlor. f3v 

Sodii hyposulphit., fsiss. M. 

This bleaches them. They are then 
washed with hot water and potash soap 
and kept in 1-1000 bichloride or 1-20 
carbolic solution. (Keller.) 

Infected sponges. Keep in lukewarm 
water for twenty-four hours, or better 
still, in running water for the same 
time ; then wash with potash soap and 
warm water and keep in 1-1000 bichlo- 
ride or 1-20 carbolic. 



THE WOUND. 

Unless it is infected, the wound need 
not be flushed or irrigated with irri- 
tating antiseptic solutions. If the me- 
chanical effect of irrigation is necessary, 
sterilized water containing three-quar- 
ter per cent, of common salt may be 
employed. 

If the wound is probably infected, 
irrigate with 1-500 bichloride solution, 
subsequently flushing out with a weaker 
lotion varying in strength from 1-2000 
to 1-5000. 

In operations about the mouth, blad- 
der, intestines, etc., boric acid solution 
or the sterilized salt solution may be 
used. 

DRESSINGS. 

Typical Lister dressing. 

1. Silkprotectwe, which is made from 
oiled silk, coated with copal varnish, 
and then with a mixture prepared as 
follows : — 

R-. Dextrine, 5j 

Starch, 5ij 

Carbolic sol. 1-20, fsij. 

2. Moist compresses. Moist carbolized 
gauze, six thicknesses, somewhat larger 
than the wound, and wrung out of 1-20 
carbolic solution. 

3. The antiseptic gauze, seven layers. 
This gauze is preserved in parchment 
paper, and is made as follows : — 

Take cheese-cloth cut in pieces about 
six yards long and one yard wide, soak 
in boiling water for two or three hours, 
and stretch to dry, after saturating 
with the following : — 

Carbolic acid, (crystals), 5j 
Resin, 5v 

Parafline (solid), 5vij. 



4. Makintosh, which is a cloth made 
impervious by means of caoutchouc. 

5. The eighth layer of gauze. 



6. Bandage, made of muslin or gauze 
saturated with 1-50 carbolic acid. 



7. Cotton and bandage. 

The ordinary bichloride dressing is 
applied as follows : — 

1. Protective. 

2. Several layers of bichloride gauze 
wrung out in carbolic solution 1-20, and 
large enough to overlap the protective 
everywhere. 

3. Many (10-20) layers of bichloride 
gauze wrung out in 1-1000, and large 
enough to overlap the preceding dress- 
ing. 

4. Bichloride cotton overlapping the 
preceding dressing (No. 3). 

5. Wet (1-2000) gauze bandage and dry 
gauze or muslin bandage. 

BICHLORIDE GAUZE. 
Boil cheese cloth in water made alka- 
line by the addition of washing-soda, 
wring out in hot water, again boil in 
water without the addition of the soda, 
run it through a bichloride solution of 
1-200, and pack away moist in jars that 
have been previously washed in the same 
solution. This gauze should be wrung 
out in a solution of bichloride 1-1000 
immediately before being applied to 
the surface of the body. 



1$. Gauze, 15,500 gr. 

Hydrarg. chlor. corros., 77 gr. 
Sodii chloridi, 
Glycerine, 
Aquae, 



7750 gr. 
1550 gr. 

68 fs. M. 

(Maas.) 



LISTER'S DOUBLE CYANIDE GAUZE. 

Wash all utensils used in preparing 
this gauze in 

IJ.. Sol. of bichlor., 1-500, 

Sol. carbol. ae.,1-20, aa equal parts. 
M. 
Then add gr. c of double cyanide of mer- 
cury and zinc (Lister) to four pints of a 
1 to 4000 solution of bichloride of mer- 
cury. 

(Keep this well stirred, since it does 
not form a solution ; the double cyanide 
is only in suspension in the bichloride 
solution.) 

Run plain gauze through it and pack 
away moist. 



SURGERY. 



335 



The double cyanide salt is prepared 
as follows : 

Cyanide of potassium, gr. 130. 
Cyanide of mercury, gr. 252. 
Mix and dissolve in water, f3xss. 
Add this solution to — 

Zinc sulphate, gr. 287. 

Water, fsiv. 

Collect the resulting precipitate and 
wash with water fSviii divided into two 
portions. Diffuse the precipitate by 
means of mortar and pestle in distilled 
water fSviii containing hematoxylin 

fr. 1%, and a drop of a solution made 
y adding stronger ammonia f5j to dis- 



tilled water fsxv ; let this mixture 
stand for several hours. The dyed salt 
is then drained and dried at a mode- 
rate heat. 



SOLUTION FOR CARBOLIZED 
GAUZE. 
Resin, 3iv 

Alcohol, f3xx 

Castor-oil, f$% 

Carbolic acid, f$ij%- M. 

Run gauze through this solution and 
up to dry. 

(University Hospital.) 



INDEX. 



ABSCESS, acute, 27 
bone, 171 

Brodie's, 171 

chronic, 29 

diploe, 78 

follicular, 214 

mammary, 255 

mediastinal, 134 

periosteal, 169 

periurethral, 215 

residual, 30 

tubercular, 29 
Ambulatory dressing, 112 
Amputation, 284 

Carden's, 288 

Chopart's, 286 

Dupuytren's, 291 

Gritti's, 288 

Hey's, 286 

i n coxalgia, 165 

in fracture, 110 

in gangrene, 43 

in gunshot wounds, 71 

Larrey's 291 

Lisfranc's, 286 

Pirogoff's, 286 

Sedillot's, 287 

Syme's, 287 

Teale's, 285 
Anaesthetics, 260 
Ankylosis, 168 

in coxalgia, 165 

in fracture, 121 
Aneurism, anastomotic, 246 

arterio-venous, 74 

cirsoid, 246 

classification, 247 

traumatic, 74 

varicose, 74 
Aneurismal varix, 74 
Angioma, 246 

Antiseptic treatment, 44, 66 
Antivenine, 73 
Anus, artificial, 187 

diseases of, 200 

22 



Anus, fissure, 204 

fistula, 204 

malformation, 200 

pruritus, 207 

ulceration, 205 
Appendicitis, 195 
Arthrectomy, 280 
Arthritis, 161 

gelatinous, 162 

rheumatoid, 167 

strumous, 162 
of hip-joint, 163 
of knee-joint, 166 

BALANITIS, 214 
Balano-posthitis, 214 
Bandages, handkerchief, 31 
Barton's 314 
roller, 296 
Barton's, 305 
Desault's, 300 
Gibson's, 306 
Velpeau's, 299 
Barton's cravat, 314 
fracture, 122 
head bandage, 305 
Bed-sore, 41 
Bites, 72 

Bladder, atony, 231 
bar at neck, 228 
exstrophy, 229 
inflammation, 230 
paralysis, 231 
rupture, 229 
tumors, 229 
Bone, diseases, 169 
syphilis, 173 
tubercle, 173 
Brodie's abscess, 171 
Bronchotomy, 252 
Bronchus, foreign body, 252 
Bubo d'emblee, 213 
gonorrheal, 215 
primary, 213 
syphilitic, 208 

337 






338 



INDEX. 



Bunions, 258 
Burns, 102 
Bursa, dropsy, 258 
Bursitis, 258 



CALCULI, vesical, 235 
Callus, 109 
Canal, femoral, 192 

inguinal, 189 
Cancrum oris, 40 
Carbuncle, 42 
Caries, 172 
Catheter, Mercier, 233 

olive-pointed, 222 

prostatic, 233 

railroad, 222 
Cellulitis, 52 
Chancre, 208 
Chancroid, 212 
Chilblain, 251 
Chloroform, 261 
Chordee, 216 
Cicatrization, 31 
Circumclusion, 63 
Clap, 213 
Cleft palate, 257 
Club-foot, 256 
Cock's perineal section, 224 
Cold, effects of, 251 
Colles's law, 212 
Compression, cerebral, 84 
Concussion, cerebral, 83 

of lung, 94 
Contusion, abdominal, 96 

cerebral, 83 

of cranium, 78 

of scalp, 77 
Counter-irritation, 23 
Cowperitis, 215 
Coxalgia, 163 

diagnosis, 166 
Cupping, 22 
Cystitis, 230 
Cysts, 295 
Czerny's suture, 99 

DELIRIUM tremens, 46 
Diffused aneurism, 74, 247 
Dilatation of stricture, 222 
Discharge, urethral, 217 
Dislocation, see Luxation. 
Dissecting aneurism, 247 
wound, 71 



Double inclined plane, 130 
Dressing, ambulatory, 112 

Lister's, 67 
Dupuytren's splint, 133 

EMBBYONIC tissue, 18 
Emphysema, 94 
Encephalitis, 86 
Enterocele, 180 
Entero-epiplocele, 180 
Epididymitis, 215 
Epiplocele, 180 
Epispadia, 219 
Erysipelas, 50 
Ether, 260 
Excision, 280 

ankle-joint, 283 

elbow -joint, 281 

hip-joint, 281 

in coxalgia, 165 

knee-joint, 282 

shoulder-joint, 280 

wrist-joint, 281 
Extension apparatus, 129 
Extravasation, intracranial, 81 

of urine, 225 

F^CES, impaction of, 206 
False joint, 111 
passage, 221 
Fever, hectic, 50 

inflammatory, 48 
pysemic, 49 
septicemic, 48 
traumatic, 47 
Fissure, anal, 204 

of Eolando, 88 
Fistula, anal, 204 
faecal, 187 
salivary, 90 
Forcipressure, 62 
Foreign body in brain, 87 
in bronchus, 252 
in larynx, 252 
in oesophagus, 254 
Fractures, 105 

anaesthetics in, 112 
Barton's, 122 
clavicle, 114 
coccvx, 126 
Colles's, 122 
compound, 108 
delayed union in, 110 



INDEX. 



339 



Fractures, delirium tremens in, 136 

diagnosis, 107 

femur, 126 

fibula, 132 

humerus, 117 

hyoid bone, 114 

inferior maxilla, 113 

larynx, 114 

metacarpus, 125 

nasal bone, 112 

non-union in, 110 

patella, 131 

pelvis, 125 

phalanges, 125 

Pott's, 132 

radius, 122 

ribs, 134 

sacrum, 126 

scapula, 116 

skull, 78 

Smith's, 122 

sternum, 134 

superior maxilla, 113 

T, 117 

tarsus, 134 

tibia, 132 

treatment, 107 

ulna, 121 

ununited, 110 

vertebrae, 135 

vicious union, 111 
Fracture-box, 133 
Frost-bite, 251 
Furuncle, 41 

GANGLION, 258 
Gangrene, 38 
Germ theory, 44 
Glanders, 55 
Gleet, 217 
Gonorrhoea, acute, 213 

chronic, 217 

in women, 218 
Granulations, 31 
Granulomata, infective, 294 
Gumma, 210 

HEMATOCELE, 241 
Hematuria, 222 
Haemophilia, 177 
Hsemothorax, 93 

Halsted's operation for hernia, 181 
Hare-lip, 257 
Hemorrhage, 57 



Hemorrhage, arrest of, 58 

bladder, 232 

kidney, 232 

urethra, 232 
Hemorrhoids, 201 
Hernia, 179 

cerebri, 87 

classification, 180 

congenital, 188, 191 

crural, 192 

encysted, 188, 191 

femoral, 192 

incarcerated, 182 

infantile, 188, 191 

inflamed, 182 

inguinal, 188 

irreducible, 181 

Littre's, 184 

of lung, 94 

reducible, 180 

strangulated, 183 

umbilical, 194 
Herniotomy, 186 
Hutchinson's teeth, 211 
Hydrarthrosis, 161 
Hydrocele, 240 
Hydrophobia, 54 
Hypertrophy of prostate, 227 
Hypospadia, 219 

IMPACTED fasces, 206 
Imperforate anus, 200 
Impermeable stricture, 224 
Incarcerated hernia, 182 
Incontinence, urinary, 234 
Infective granulomata, 294 
Inflammation, 17 

intracranial, 86 
Ingrowing toe-nail, 259 
Internal strangulation, 199 
Intestinal obstruction, 198 
Intussusception, 199 

T7YPH0SIS, 178 



LAPAEOTOMY, 100, 200 
Laryngotomy, 253 
Larynx, foreign body, 252 
Leeching, 23 
Lembert's suture, 99 
Ligament, coraco-humeral, 14C 
Y-, 150 



340 



INDEX. 



Ligamentous union, 135 
Ligations, 263 

anterior tibial, 278 

axillary, 270 

brachial, 271 

common carotid, 265 

dorsalis pedis, 279 

external carotid, 266 

external iliac, 274 

facial, 267 

femoral, 274 

internal mammary, 270 

lingual, 267 

occipital, 268 

palmar arches, 273 

popliteal, 276 

posterior tibial, 277 

radial, 272 

subclavian, 269 

temporal, 268 

ulnar, 273 
Litholapaxy, 237 
Litholysis, 237 
Lithotomy, 237 
Lithotrity, 237 
Localization, cerebral, 87 
Loose bodies in joints, 167 
Lordosis, 178 
Luxations, 137 

astragalus, 156 

carpus, 148 

classification, 137 

clavicle, 141 

complications, 139 

femur, 150 

humerus, 143 

jaw, 140 

metacarpus, 149 

old, 139 

patella, 155 

phalanges, 149 

radius, 148 

ribs, 141 

scapula, 143 

semilunar cartilages, 155 

tarsus, 156 

tibia, 154 

treatment, 139 

ulna, 147 



MALIGNANT pustule, 55 
Meningitis, 86 
Micro-organisms, 44 



Mortification, 38 
Mucous patch, 209 

N^VUS, capillary, 246 
venous, 246 
Necrosis, 172 
Nodes, periosteal, 169 
Noma pudendi, 41 

fT?SOPHAGUS, foreign body, 254 

VJh stricture, 254 

Onychia, 259 

Ophthalmia, 215 

Orchitis, 242 

Osteitis, 170 

deformans, 170 

rarefying, 170 
Osteomalacia, 174 
Osteomyelitis, 170 
Osteoporosis, 170 

PAGET'S disease, 255 
Paraphimosis, 214 
Paronychia, 259 
Passage of catheter, 221 
Perineal section, 224 
Periostitis, 169 

osteoplastic, 169 
Peritonitis, 97 
Pernio, 251 
Phimosis, 214 
Phlebitis, 244 
Piles, 201 

Plaster jacket, 176 
Plastic lymph, 18 
Pneumothorax, 94 
Pneumotomy, 95 
Pott's disease, 174 

puffy tumor, 78 
Poupart's ligament, 190 
Prolapsus of lung, 94 

recti, 203 
Prostatitis, 226 
Pruritus ani, 207 
Pupil in brain injury, 85 
Pus, 19 
Pysemia, 49 

RACHITIS, 176 
Kectum, diseases of, 200 
polyp, 206 
prolapse, 203 



INDEX. 



341 



Rectum, stricture, 205 

ulceration, 205 

villous tumor, 207 
Resection, 280 
Retention of urine, 232 
Retroclusion, 62 
Rheumatism, gonorrhoea^ 215 
Rickets, 176 
Ring, abdominal, 189, 190 

femoral, 193 
Rontgen rays, 315 
Rupture (see Hernia), 179 

of viscera, 96 



SALIVATION, 26 
Saphenous opening, 193 
Sarcocele, 242 

Sayre's fracture-dressing, 115 
Scalds, 102 
Scalp, layers, 75 

wounds, 77 
Schede's method of treating varicose 

veins, 243 
Scoliosis, 178 
Scrofula, 177 
Septicaemia, 48 
Shock, 45 

ether in, 262 
Sinus, 30 
Skin grafts, 37 
Spine, curvature, 177 
Splints, Bond's, 124 

coxalgia, 165 

Dupuytren's, 133 
Sprain, 158 

fracture, 158 

of back, 159 
Staphyloplasty, 257 
Staphylorrhaphy, 257 
Stimulants, 25 
Stings, 72 

Stone in bladder, 235 
Strapping chest, 135 
Stricture, urethra, 219 
Struma, 177 
Sutures, 65 
Synovitis, 160 

gonorrhceal, 215 
Syphilis, 208 



TALIPES, 256 
Tapping abdomen, 100 
bladder, 234 



Tapping pericardium, 95 

pleura, 95 
Taxis, 184 
Tenosynovitis, 258 
Tetanus, 52 
Thrombosis, 244 
Torsion, 61 
Torsoclusion, 62 
Trachea, foreign body in, 252 
Tracheotomy, 253 
Transfusion, 59 
Trephining, 89 
Triangles of neck, 264 
Trophic changes, 75 
Tubercle, 173 
Tumors, 292 

of breast, 255 

classification, 293 

cystic, 295 

treatment, 293 

ULCERATION, 31 
Ulcers, 32 
Uranoplasty, 257 
Urethra, 213 

deformities, 219 
rupture, 225 
stricture, 219 
Urethrotome, 223 
Urethrotomy, 223 

VARICOCELE, 242 
Varicose aneurism, 74 
veins, 245 
Varix, 245 

aneurismal, 74 
arterial, 246 
Veins, diseases of, 244 
varicose, 245 
wounds of, 75 
Venereal disease, 208 
Vesication, 24 
Volvulus, 199 

WALLERIAN degeneration, 74 
White swelling, 162 
hip-joint, 163 
knee-joint, 166 
Wounds, 44 

abdomen, 95 
arteries, 73 
chest, 92 
classification, 68 



342 



INDEX. 



Wounds, contused, 
dissecting, 72 
face, 90 
gunshot, 70 
incised, 69 
joints, 159 
lacerated, 69 
neck, 91 



Wounds, nerves, 75 
oesophagus, 92 
poisoned, 71 
punctured, 69 
scalp, 77 
trachea, 92 
veins, 75 
Y -ligament, 151 



Medical and Surgical Works 



PUBLISHED BY 



W. B. SAUNDERS, 925 Walnut Street, Philadelphia, Pa. 



PAGE 

Abbott on Transmissible Diseases . . . . 18 
American Pocket Medical Dictionary . . 35 
^American Text-Book of Applied Thera- 
peutics 8 

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Ashton's Obstetrics . ■ 43 

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Ball's Bacteriology 43 

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Brockway's Physics 43 

Burr's Nervous Diseases 41 

Butler's Materia Medica and Therapeutics 24 
Cema's Notes on the Newer Remedies . . 32 
Chapin's Compendium of Insanity .... 35 
Chapman's Medical Jurisprudence . . . . 41 
Church and Peterson's Nervous and Men- 
tal Diseases 17 

Clarkson's Histology 33 

Cohen and Eshner's Diagnosis 43 

Corwin's Diagnosis of the Thorax .... 37 

Cragin's Gynaecology 43 

Crookshank's Text-Book of Bacteriology . 27 

DaCosta's Manual of Surgery 23 

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Dorland's Pocket Medical Dictionary . . 35 

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Frothingham's Bacteriological Guide ... 30 

Garrigues' Diseases of Women 34 

Gleason's Diseases of the Ear 43 

*Gould and Pyle's Curiosities of Medicine . 17 

Grafstrom's Massage 28 

Griffith's Care of the Baby . . , 38 

Griffith's Infant's Weight Chart 39 

Gross's Autobiography 26 

Hampton's Nursing 39 

Hare's Physiology 43 

Hart's Diet in Sickness and in Health . . 36 

Haynes' Manual of Anatomy 41 

Heisler's Embryology 19 

Hirst's Obstetrics 20 

Hyde's Syphilis and Venereal Diseases . . 41 
International Text-Book of Surgery ... 6 

Jackson's Diseases of the Eye 19 

Jackson and Gleason's Diseases of the Eye, 

Nose, and Throat 43 

Keating's Pronouncing Dictionary .... 26 

Keating's Life Insurance 39 

Keen's Operation Blanks 36 

Keen's Surgery of Typhoid Fever .... 22 



PAGE 

Kyle's Diseases of Nose and Throat ... 18 

Laine's Temperature Charts 32 

Lockwood's Practice of Medicine . . . . ai 

Long's Syllabus of Gynecology 34 

Macdonald's Surgical Diagnosis and Treat- 
ment 22 

McFarland's Pathogenic Bacteria .... 30 
Mallory and Wright's Pathological Tech- 
nique 22 

Martin's Surgery 43 

Martin's Minor Surgery, Bandaging, and 

Venereal Diseases 43 

Meigs' Feeding in Early Infancy 30 

Moore's Orthopedic Surgery 23 

Morris' Materia Medica and Therapeutics 43 

Morris' Practice of Medicine 43 

Morten's Nurses' Dictionary 38 

Nancrede's Anatomy and Dissection ... 31 

Nancrede's Anatomy 43 

Nancrede's Principles of Surgery .... 19 
Norris 1 Syllabus of Obstetrical Lectures . 37 

Penrose's Diseases of Women 24 

Powell's Diseases of Children 43 

Pryor's Pelvic Inflammations 33 

Pye's Bandaging and Surgical Dressing . 23 

Raymond's Physiology 41 

Saundby's Renal and Urinary Diseases . . 25 
*Saunders' American Year-Book of Medi- 
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Saunders' Medical Hand-Atlases . . . 3, 4, 5 
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Sayre's Practice of Pharmacy 43 

Semple's Pathology and Morbid Anatomy 43 
Semple's Legal Medicine, Toxicology, and 

Hygiene .' 43 

Serin's Genito-L^rinary Tuberculosis ... 24 

Senn's Tumors 25 

Senn's Syllabus of Lectures on Surgery . . 37 
Shaw's Nervous Diseases and Insanity . . 43 

Starr's Diet-Lists for Children 38 

Stelwagon's Diseases of the Skin 43 

Stengel's Pathology 20 

Stevens' Materia Medica and Therapeutics 32 

Stevens' Practice of Medicine 31 

Stewart's Manual of Physiology 37 

Stewart and Lawrance's Medical Elec- 
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Stoney's Materia Medica for Nurses ... 31 
Stoney's Practical Points in Nursing ... 27 
Sutton and Giles' Diseases of Women . 29, 41 
Thomas's Diet-List and Sick-Room Diet- 
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Thornton's Dose-Book and Manual of Pre- 
scription-Writing 41 

Van Valzah and Nisbet's Diseases of the 

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Vecki's Sexual Impotence 33 

Vierordt and Stuart's Medical Diagnosis . 28 

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or two on thirty days' time if credit is desired ; larger purchases 
on monthly payment plan. See offer below. 

HOW to Send There are four ways by which money can be sent at our risk, 

Money by namely : a post-office money order, an express money order, a 
Mail. bank-check (draft), and in a registered letter. Money sent in any 

other way is at the sender's risk. Silver should not be sent through 

the mail. 

Shipments. All books, being packed in patent metal-edged boxes, neces- 

sarily reach our patrons by mail or express in excellent condi- 
tion. 



Subscription 
Books. 



Miscellaneous 



Books. 



Latest 
Editions. 

Bindings. 



Books in this catalogue marked with a star (*) are for sale by 
subscription only, and may be secured by ordering them through 
any of our authorized travelling salesmen, or direct from the 
Philadelphia office: they are not for sale by booksellers. All 
other books in our catalogue can be procured of any bookseller 
at the advertised price, or directly from us. 

We carry in stock only our own publications, but can supply 
the publications of other houses (except subscription books) on 
receipt of publisher's price. 

In every instance the latest revised edition is sent. 

In ordering, be careful to state the style of binding desired- 
Cloth, Sheep, or Half Morocco. 



Special Offer. To physicians of approved credit who furnish satisfactory 

Monthly references books will be sent express prepaid ; terms, $5.00 cash 
Payment upon delivery of books, and monthly payments of $5 00 thereafter 
Flan. until full amount is paid. Any of the publications of W. B. Saunders 

(100 titles to select from) may be had in this way at catalogue price, 
including the American Text-Book Series, the Medical Hand- 
Atlases, etc. All payments to be made by mail or otherwise, free 
of all expense to us. 



SAUNDERS' 
MEDICAL HAND-ATLASES. 



The series of books included under this title consists of authorized translations 
into English of the world-famous Lehmann Medicinische Handatlanten, 
which for scientific accuracy, pictorial beauty, compactness, and cheap- 
ness surpass any similar volumes ever published. Each volume contains from 
50 to 100 colored plates, executed by the most skilful German lithographers, 
besides numerous illustrations in the text. There is a full and appropriate de- 
scription, and each book contains a condensed but adequate outline of the 
subject to which it is devoted. 

In planning this series arrangements were made with representative pub- 
lishers in the chief medical centers of the world for the publication of transla- 
tions of the atlases into nine different languages, the lithographic plates for all 
being made in Germany, where work of this kind has been brought to the greatest 
perfection. The enormous expense of making the plates being shared by the 
various publishers, the cost to each one was reduced to practically one-tenth. 
Thus by reason of their universal translation and reproduction, affording in- 
ternational distribution, the publishers have been enabled to secure for these 
atlases the best artistic and professional talent, to produce them in the most 
elegant style, and yet to offer them at a price heretofore unapproached 
in cheapness. The great success of the undertaking is demonstrated by the 
fact that the volumes have already appeared in thirteen different languages 
—German, English, French, Italian, Russian, Spanish, Japanese, Dutch, Danish, 
Swedish, Roumanian, Bohemian, and Hungarian. 

In view of the unprecedented success of these works, Mr. Saunders has con- 
tracted with the publisher of the original German edition for one hundred 
thousand copies of the atlases. In consideration of this enormous under- 
taking, the publisher has been enabled to prepare and furnish special additional 
colored plates, making the series even handsomer and more complete than 
was originally intended. 

As an indication of the great practical value of the atlases and of the im- 
mense favor with which they have been received, it should be noted that the 
Medical Department of the U. S. Army has adopted the "Atlas of Opera- 
tive Surgery," as its standard, and has ordered the book in large quantities for 
distribution to the various regiments and army posts. 

The same careful and competent editorial supervision has been secured in 
the English edition as in the originals. The translations have been edited by 
the leading American specialists in the different subjects. 

(For List of Volumes in this Series, see next two pages. ) 
3 



SAUNDERS' MEDICAL HAND-ATLASES. 

VOLUMES NOW READY. 

Atlas and Epitome of Internal Medicine and Clinical Diagnosis. 

By Dr. Chr. Jakob, of Erlangen. Edited by Augustus A. Eshner, M. D., 
Professor of Clinical Medicine, Philadelphia Polyclinic. With 68 colored 
plates, 64 text-illustrations, and 259 pages of text. Cloth, $3.00 net. 

" The charm of the book is its clearness, conciseness, and the accuracy and beauty of its 
illustrations. It deals with facts. It vividly illustrates those facts. It is a scientific work 
put together for ready reference." — Brooklyn Medical Journal. 

Atlas of Legal Medicine. By Dr. E. R. von Hofmann, of Vienna. Edited 
by Frederick Peterson, M. D., Chief of Clinic, Nervous Dept., College 
of Physicians and Surgeons, New York. With 120 colored figures on 56 
plates, and 193 beautiful half-tone illustrations. Cloth, $3.50 net. 

" Hofmann's 'Atlas of Legal Medicine' is a unique work. This immense field finds in this 
book a pictorial presentation that far excels anything with which we are familiar in any other 
work." — Philadelphia Medical Journal. 

Atlas and Epitome of Diseases of the Larynx. By Dr. L. Grunwald, 
of Munich. Edited by Charles P. Grayson, M. D., Physician-in-Charge, 
Throat and Nose Department, Hospital of the University of Pennsylvania. 
With 107 colored figures on 44 plates, 25 text-illustrations, and 103 pages 
of text. Cloth, $2.50 net. 

"Aided as it is by magnificently executed illustrations in color, it cannot fail of being of 
the greatest advantage to students, general practitioners, and expert laryngologists." — St. 
Louis Medical and Surgical Journal. 

Atlas and Epitome of Operative Surgery. By Dr. O. Zuckerkandl, 
of Vienna. Edited by J. Chalmers DaCosta, M. D., Clinical Professor 
of Surgery, Jefferson Medical College, Philadelphia. With 24 colored plates, 
217 text-illustrations, and 395 pages of text. Cloth, $3.00 net. 

" We know of no other work that combines such a wealth of beautiful illustrations with 
clearness and conciseness of language, that is so entirely abreast of the latest achievements, 
and so useful both for the beginner and for one who wishes to increase his knowledge of oper- 
ative surgery." — Munchener medicinische Wochenschrift. 

Atlas and Epitome of Syphilis and the Venereal Diseases. By 

Prof. Dr. Franz Mracek, of Vienna. Edited by L. Bolton Bangs, 
M. D., Professor of Genito- Urinary Surgery, University and Bellevue Hos- 
pital Medical College, New York. With 71 colored plates, 16 black-and- 
white illustrations, and 122 pages of text. Cloth, $3.50 net. 

"A glance through the book is almost like actual attendance upon a famous clinic." — 
Journal of the American Medical Association. 

Atlas and Epitome of External Diseases of the Eye. By Dr. O 

Haab, of Zurich. Edited by G. E. de Schweinitz, M. D., Professor of 
Ophthalmology, Jefferson Medical College, Philadelphia. With 76 colored 
illustrations on 40 plates, and 228 pages of text. Cloth, $3.00 net. 

" It is always difficult to represent pathological appearances in colored plates, but this 
work seems to have overcome these difficulties, and the plates, with one or two exceptions, 
are absolutely satisfactory." — Boston Medical and Surgical Journal. 

Atlas and Epitome of Skin Diseases. By Prof. Dr. Franz Mracek, 
of Vienna. Edited by Henry W. Stelwagon, M. D., Clinical Professor 
of Dermatology, Jefferson Medical College, Philadelphia. With 63 colored 
plates, 39 half-tone illustrations, and 200 pages of text. Cloth, $3.50 net. 
"The importance of personal inspection of cases in the study of cutaneous diseases is 
readily appreciated, and next to the living subjects are pictures which will show the appear- 
ance of the disease under consideration. ■ Altogether the work will be found of very great 
value to the general practitioner."— Journal of the American Medical Association. 

4 



SAUNDERS' MEDICAL HAND-ATLASES- 



VOLUMES IN PRESS FOR EARLY PUBLICATION. 

Atlas and Epitome of Diseases Caused by Accidents. By Dr. Ed. 

Golebiewski, of Berlin. Translated and edited with additions by Pearce 
Bailey, M.D., Attending Physician to the Department of Corrections 
and to the Almshouse and Incurable Hospitals, New York. With 40 
colored plates, 143 text-illustrations, and 600 pages of text. 

Atlas and Epitome of Special Pathological Histology. By Dr. H. 
Durck, of Munich. Edited by Ludvig Hektoen, M.D., Professor of 
Pathology, Rush Medical College, Chicago. Two volumes, with about 
120 colored plates, numerous text-illustrations, and copious text. 

Atlas and Epitome of General Pathological Histology. With an 
.Appendix on Patho-histological Technic. By Dr. H. DOrCK, of Munich. 
Edited by Ludvig Hektoen, M.D., Professor of Pathology, Rush Medi- 
cal College, Chicago. With 80 colored plates, numerous text-illustrations, 
and copious text. 

Atlas and Epitome of Gynecology. By Dr. O. Schaffer, of the 
University of Heidelberg. With 90 colored plates, 65 text- illustrations, 
and 308 pages of text. Edited by Richard C. Norris, A. M., M. D., 
Gynecologist to the Philadelphia and the Methodist Episcopal Hospitals. 

IN PREPARATION. 

Atlas and Epitome of Orthopedic Surgery. By Dr. Schultess and 

Dr. Luning, of Zurich. About 100 colored illustrations. 
Atlas and Epitome of Operative Gynecology. By Dr. O. Schaffer, 

of Heidelberg. With 40 colored plates and numerous illustrations in 

black and white from original paintings. 
Atlas and Epitome of Diseases of the Ear. Edited by Prof. Dr. 

Politzer, of Vienna, and Dr. G. Bruhl, of Berlin. With 120 colored 

illustrations and about 200 pages of text. 
Atlas and Epitome of General Surgery. Edited by Dr. Marwedel, 

with the cooperation of Prof. Dr. Czerny. With about 200 colored 

illustrations. 

Atlas and Epitome of Psychiatry. By Dr. Wilh. Weygandt, of Wiirz- 

burg. With about 120 colored illustrations. 
Atlas and Epitome of Normal Histology. By Dr. Johannes Sobotta, 

of Wurzburg. With 80 colored plates and numerous illustrations. 
Atlas and Epitome of Topographical Anatomy. By Prof. Dr. 

Schultze, of Wurzburg. About 100 colored illustrations and a very 

copious text. 

5 



W. B. SAUNDERS- 



*THE INTERNATIONAL TEXT-BOOK OF SURGERY. In 
two volumes. By American and British authors. Edited by J. Col- 
lins Warren, M.D.,LL.D., Professor of Surgery, Harvard Medical School, 
Boston ; Surgeon to the Massachusetts General Hospital ; and A. Pearce 
Gould, M. S., F. R. C. S., Eng., Lecturer on Practical Surgery and Teacher 
of Operative Surgery, Middlesex Hospital Medical School ; Surgeon to the 
Middlesex Hospital, London, England. Vol. I. — General and Operative 
Surgery. — Handsome octavo volume of 947 pages, with 458 beautiful 
illustrations, and 9 lithographic plates. Vol. II. — Special or Regional 
Surgery. — Handsome octavo volume of 1050 pages, with over 500 wood- 
cuts and half-tones, and 8 lithographic plates. Prices per volume : Cloth, 
$5.00 net; Half-Morocco, $6.00 net. 

Just Issued. 

In presenting a new work on surgery to the medical profession the publisher 
feels that he need offer no apology for making an addition to the list of excellent 
works already in existence. Modern surgery is still in the transition stage of its 
development. The art and science of surgery are advancing rapidly, and the 
number of workers is now so great and so widely spread through the whole of 
the civilized world that there is certainly room for another work of reference 
which shall be untrammelled by many of the traditions of the past, and shall at 
the same time present with due discrimination the results of modern progress. 
There is a real need among practitioners and advanced students for a work on 
surgery encyclopedic in scope, yet so condensed in style and arrangement that 
the matter usually diffused through four or five volumes shall be given in one- 
half the space and at a correspondingly moderate cost. 

The ever-widening-field of surgery has been developed largely by special 
work, and this method of progress has made it practically impossible for one 
man to write authoritatively on the vast range of subjects embraced in a modern 
text-book of surgery. In order, therefore, to accomplish their object, the editors 
have sought the aid of men of wide experience and established reputation in the 
various departments of surgery. 

CONTRIBUTORS : 



Dr. Robert W. Abbe. 
C. H.Golding Bird. 
E. H. Bradford. 
W. T. Bull. 
T. G. A. Burns. 
Herbert L. Burrell. 
R. C. Cabot. 
I. H. Cameron. 
James Cantlie. 
W. Watson Cheyne. 
William B. Clarke. 
William B. Coley. 
Edw. Treacher Collins. 
H. Holbrook Curtis. 
J. Chalmers Da Costa. 
N. P. Dandridge. 
John B. Deaver. 
J. W. Elliot. 
Harold Ernst. 



Dr. Christian Fenger. 
W. H. Forwood. 
George R. Fowler. 
George W. Gay. 
A. Pearce Gould. 
J. Orne Green. 
John B. Hamilton. 
M. L. Harris: 
Fernand Henrotin. 
G. H. Makins. 
Rudolph Matas. 
Charles McBurney. 
A. J. McCosh. 
L. S. McMurtry. 
J. Ewing Mears. 
George H. Monks. 
John Murray. 
Robert W. Parker. 



Dr. Rush ton Parker. 
George A. Peters. 
Franz Pfaff. 
Lewis S. Pilcher. 
James J. Putnam. 
M. H. Richardson. 
A. W. Mayo Robson. 
W. L. Rodman. 
C. A. Siegfried. 
G. B. Smith. 
W. G. Spencer. 
J. Bland Sutton. 
L. McLane Tiffany. 
H. Tuholske. 
Weller Van Hook. 
James P. Warbasse. 
J. Collins Warren. 
De Forest Willard. 



CATALOGUE OF MEDICAL WORKS. 



*AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. Edited by 
William H. Howell, Ph. D., M. D., Professor of Physiology in the 
Johns Hopkins University, Baltimore, Md. One handsome octavo volume 
of 1052 pages, fully illustrated. Prices: Cloth, $6.00 net; Sheep or Half- 
Morocco, $7.00 net. 

This work is the most notable attempt yet made in America to combine in 
one volume the entire subject of Human Physiology by well-known teachers 
who have given especial study to that part of the subject upon which they write. 
The completed work represents the present status of the science of Physiology, 
particularly from the standpoint of the student of medicine and of the medical 
practitioner. 

The collaboration of several teachers in the preparation of an elementary text- 
book of physiology is unusual, the almost invariable rule heretofore having been 
for a single author to write the entire book. One of the advantages to be derived 
from this collaboration method is that the more limited literature necessary for 
consultation by each author has enabled him to base his elementary account 
upon a comprehensive knowledge of the subject assigned to him ; another, and 
perhaps the most important, advantage is that the student gains the point of view 
of a number of teachers. In a measure he reaps the same benefit as would be 
obtained by following courses of instruction under different teachers. The 
different standpoints assumed, and the differences in emphasis laid upon the 
various lines of procedure, chemical, physical, and anatomical, should give the 
student a better insight into the methods of the science as it exists to-day. The 
work will also be found useful to many medical practitioners who may wish to 
keep in touch with the development of modern physiology. 

CONTRIBUTORS : 



HENRY P. BOWDITCH, M. D., 

Professor of Physiology, Harvard Medi- 
cal School. 

JOHN G. CURTIS, M. D., 

Professor of Physiology, Columbia Uni- 
versity, N. Y. (College of Physicians 
and Surgeons). 

HENRY H. DONALDSON, Ph.D., 

Head-Professor of Neurology, Univer- 
sity of Chicago. 

W. H. HOWELL, Ph. D., M. D., 

Professor of Physiology, Johns Hopkins 
University. 

FREDERIC S. LEE, Ph. D., 

Adjunct Professor of Physiology, Colum- 
bia University, N. Y. (College of 
Physicians and Surgeons). 



WARREN P. LOMBARD, M.D., 

Professor of Physiology, University of 
Michigan. 

GRAHAM LUSK, Ph.D., 

Professor of Physiology, Yale MedicaF 
School. 

W. T. PORTER, M.D., 

Assistant Professor of Physiology, Har- 
vard Medical School. 

EDWARD T. REICHERT, M.D., 

Professor of Physiology, University of 
Pennsylvania. 

HENRY SEW ALL, Ph.D., M. D., 

Professor of Physiology, Medical Depart- 
ment, University of Denver. 



" We can commend it most heartily, not only to all students of physiology, but to every 
physician and pathologist, as a valuable and comprehensive work of reference, written by 
men who are of eminent authority in their own special subjects." — London Lancet. 

" To the practitioner of medicine and to the advanced student this volume constitutes, 
we believe, the best exposition of the present status of the science of physiology in the Eng- 
lish language." — American Journal of the Medical Sciences. 



8 W. B. SAUNDERS' 



*AN AMERICAN TEXT-BOOK OF APPLIED THERAPEU- 
TICS. For the Use of Practitioners and Students. Edited by 
James C. Wilson, M. D., Professor of the Practice of Medicine and of 
Clinical Medicine in the Jefferson Medical College. One handsome octavo 
volume of 1326 pages. Illustrated. Prices: Cloth, $7.00 net; Sheep or 
Half-Morocco, $8.00 net. 

The arrangement of this volume has been based, so far as possible, upon 
modern pathologic doctrines, beginning with the intoxications, and following 
with infections, diseases due to internal parasites, diseases of undetermined 
origin, and finally the disorders of the several bodily systems — digestive, re- 
spiratory, circulatory, renal, nervous, and cutaneous. It was thought proper to 
include also a consideration of the disorders of pregnancy. 

The articles, with two exceptions, are the contributions of American writers. 
Written from the standpoint of the practitioner, the aim of the work is to facili- 
tate the application of knowledge to the prevention, the cure, and the allevia- 
tion of disease. The endeavor throughout has been to conform to the title of 
the book — Applied Therapeutics — to indicate the course of treatment to be 
pursued at the bedside, rather than to name a list of drugs that have been used 
at one time or another. 

The list of contributors comprises the names of many who have acquired dis- 
tinction as practitioners and teachers of practice, of clinical medicine, and of 
the specialties. 

CONTRIBUTORS : 



Dr. I. E. Atkinson, Baltimore, Md. 
Sanger Brown, Chicago, III. 
John B. Chapin, Philadelphia, Pa. 
William C. Dabney, Charlottesville, Va. 
John Chalmers DaCosta, Philada., Pa. 
I. N. Danforth, Chicago, 111. 
John L. Dawson, Jr., Charleston, S. C. 
F. X. Dercum, Philadelphia, Pa. 
George Dock, Ann Arbor, Mich. 
Robert T. Edes, Jamaica Plain, Mass. 
Augustus A. Eshner, Philadelphia, Pa. 
J. T. Eskridge, Denver, Ccl. 
F. Forchheimer, Cincinnati, O. 
Carl Frese, Philadelphia, Pa. 
Edwin E. Graham, Philadelphia, Pa. 
John Guiteras, Philadelphia, Pa. 
Frederick P. Henry, Philadelphia, Pa. 
Guy Hinsdale, Philadelphia, Pa. 
Orville Horwitz, Philadelphia, Pa. 
W. W. Johnston, Washington, D. C. 
Ernest Laplace, Philadelphia, Pa. 
A. Laveran, Pans, France. 

" As a work either for study or reference it will be of great value to the practitioner, as 
it is virtually an exposition of such clinical therapeutics as experience has taught to be of 
the most value. Taking it all in all, no recent publication on therapeutics can be compared 
with this one in practical value to the working physician." — Chicago Clinical Reviezv. 

"The whole field of medicine has been well covered. The work is thoroughly practical, 
and while it is intended for practitioners and students, it is abetter book for the general 
practitioner than for the student. The young practitioner especially will find it extremely 
suggestive and helpful." — The Indian Lancet. 



Dr. James Hendrie Lloyd, Philadelphia, Pa. 
John Noland Mackenzie, Baltimore, Md. 
J. W. McLaughlin, Austin, Texas. 
A. Lawrence Mason, Boston, Mass. 
Charles K. Mills, Philadelphia, Pa. 
John K. Mitchell, Philadelphia, Pa. 
W. P. Northrup, New York City. 
William Osier, Baltimore, Md. 
Frederick A. Packard, Philadelphia, Pa. 
Theophilus Parvin, Philadelphia, Pa. 
Beaven Rake, London, England. 
E. O. Shakespeare, Philadelphia, Pa. 
Wharton Sinkler, Philadelphia, Pa. 
Louis Starr, Philadelphia, Pa. 
Henry W. Stelwagon, Philadelphia, Pa. 
James Stewart, Montreal, Canada. 
Charles G. Stockton, Buffalo, N. Y. 
James Tyson, Philadelphia, Pa. 
Victor C. Vaughan, Ann Arbor, Mich. 
James T. Whittaker, Cincinnati, O. 
J. C. Wilson, Philadelphia, Pa. 



CATALOGUE OF MEDICAL WORKS. 



*AN AMERICAN TEXT-BOOK OF OBSTETRICS. Edited by 
Richard C. Norris, M. D. ; Art Editor, Robert L. Dickinson, M. D. 
One handsome octavo volume of over iooo pages, with nearly 900 colored 
and half-tone illustrations. Prices: Cloth, $7.00 net; Sheep or Half 
Morocco, $8.00 net. 

The advent of each successive volume of the series of the American Text- 
Books has been signalized by the most flattering comment from both the Press 
and the Profession. The high consideration received by these text-books, and 
their attainment to an authoritative position in current medical literature, have 
been matters of deep international interest, which finds its fullest expression in 
the demand for these publications from all parts of the civilized world. 

In the preparation of the "American Text-Book of Obstetrics" the 
editor has called to his aid proficient collaborators whose professional prominence 
entitles them to recognition, and whose disquisitions exemplify Practical 
Obstetrics. While these writers were each assigned special themes for dis- 
cussion, the correlation of the subject-matter is, nevertheless, such as ensures 
logical connection in treatment, the deductions of which thoroughly represent 
the latest advances in the science, and which elucidate the best modern methods 
of procedure. 

The more conspicuous feature of the treatise is its wealth of illustrative 
matter. The production of the illustrations had been in progress for several 
years, under the personal supervision of Robert L. Dickinson, M. D., to whose 
artistic judgment and professional experience is due the most sumptuously 
illustrated work of the period. By means of the photographic art, combined 
with the skill of the artist and draughtsman, conventional illustration is super- 
seded by rational methods of delineation. 

Furthermore, the volume is a revelation as to the possibilities that may be 
reached in mechanical execution, through the unsparing hand of its publisher. 



CONTRIBUTORS : 



Dr. James C. Cameron. 
Edward P. Davis. 
Robert L. Dickinson. 
Charles Warrington Earle. 
James H. Etheridge. 
Henry J. Garrigues. 
Barton Cooke Hirst. 
Charles Jewett. 



Dr. Howard A. Kelly. 
Richard C. Norris. 
Chauncey D. Palmer. 
Theophilus Parvin. 
George A. Piersol. 
Edward Reynolds. 
Henry Schwarz. 



"At first glance we are overwhelmed by the magnitude of this work in several respects, 
viz. : First, by the size of the volume, then by the array of eminent teachers in this depart- 
ment who have taken part in its production, then by the profuseness and character of the 
illustrations, and last, but not least, the conciseness and clearness with which the text is ren- 
dered. This is an entirely new composition, embodying the highest knowledge of the art as 
it stands to-day by authors who occupy the front rank in their specialty, and there are many 
of them. We cannot turn over these pages without being struck by the superb illustrations 
which adorn so many of them. We are confident that this most practical work will find 
instant appreciation by practitioners as well as students." — New York Medical Times. 

Permit me to say that your American Text-Book of Obstetrics is the most magnificent 
medical work that 1 have ever seen. I congratulate you and thank you for this superb work> 
which alone is sufficient to place you first in the ranks of medical publishers. 

With profound respect I am sincerely yours, Alex. J. C. Skene. 



IO 



W. B. SAUNDERS' 



*AN AMERICAN TEXT-BOOK OF THE THEORY AND 
PRACTICE OF MEDICINE. By American Teachers. Edited 
by William Pepper, M. D., LL.D., Provost and Professor of the Theory 
and Practice of Medicine and of Clinical Medicine in the University of 
Pennsylvania. Complete in two handsome royal- octavo volumes of about 
IOOO pages each, with illustrations to elucidate the text wherever necessary. 
Price per Volume : Cloth, $5.00 net; Sheep or Half-Morocco, $6.00 net. 



VOLUME I. CONTAINS s 



Hygiene. — Fevers (Ephemeral, Simple Con- 
tinued, Typhus, Typhoid, Epidemic Cerebro- 
spinal Meningitis, and Relapsing). — Scarla- 
tina, Measles, Rotheln, Variola, Varioloid, 
Vaccinia, Varicella, Mumps,Whooping-cough, 
Anthrax, Hydrophobia, Trichinosis, Actino- 



mycosis, Glanders, and Tetanus.— Tubercu- 
losis, Scrofula, Syphilis, Diphtheria, Erysipe- 
las, Malaria, Cholera, and Yellow Fever. — 
Nervous, Muscular, and Mental Diseases etc. 



VOLUME II. CONTAINS: 



Urine (Chemistry and Microscopy).— Kid- 
ney and Lungs. — Air-passages (Larynx and 
Bronchi) and Pleura. — Pharynx, (Esophagus, 
Stomach and Intestines (including Intestinal 
Parasites), Heart, Aorta, Arteries and Veins. 



— Peritoneum, Liver, and Pancreas. — Diathet- 
ic Diseases (Rheumatism, Rheumatoid Ar- 
thritis, Gout, Lithaemia, and Diabetes.) — 
Blood and Spleen. — Inflammation, Embolism, 
Thrombosis, Fever, and Bacteriology. 



The articles are not written as though addressed to students in lectures, but 
are exhaustive descriptions of diseases, with the newest facts as regards Causa- 
tion, Symptomatology, Diagnosis, Prognosis, and Treatment, including a large 
number of approved formulae. The recent advances made in the study 
of the bacterial origin of various diseases are fully described, as well as the 
bearing of the knowledge so gained upon prevention and cure. The subjects 
of Bacteriology as a whole and of Immunity are fully considered in a separate 
section. 

Methods of diagnosis are given the most minute and careful attention, thus 
enabling the reader to learn the very latest methods of investigation without 
consulting works specially devoted to the subject. 



CONTRIBUTORS : 



Dr. J. S. Billings, Philadelphia. 

Francis Delafield, New York. 
Reginald H. Fitz, Boston. 
James W. Holland, Philadelphia. 
Henry M. Lyman, Chicago. 
William Osier, Baltimore. 



William Pepper, Philadelphia. 
W. Gilman Thompson, New York. 
W. H. Welch, Baltimore. 
James T. Whittaker, Cincinnati. 
James C. Wilson, Philadelphia. 
Horatio C. Wood, Philadelphia. 



" We reviewed the first volume of this work, and said : ' It is undoubtedly one of the best 
text-books on the practice of medicine which we possess.' A consideration of the second 
a.nd last volume leads us to modify that verdict and to say that the completed work is, in our 
opinion, the best of its kind it has ever been our fortune to see. It is complete, thorough, 
accurate, and clear. It is well written, well arranged, well printed, well illustrated, and well 
bound. It is a model of what the modern text-book should be." — New York Medical Journal. 

"A library upon modern medical art. The work must promote the wider diffusion of 
sound knowledge." — American Lancet. 

" A trusty counsellor for the practitioner or senior student, on which he may implicitly 
?«ly." — Edinburgh Medical Journal. 



CATALOGUE OF MEDICAL WORKS. II 

*AN AMERICAN TEXT-BOOK OF SURGERY. Edited by Wil- 
liam W. Keen, M. D., LL.D., and J. William White, M. D., Ph. D. 
Forming one handsome royal octavo volume of 1230 pages (iox 7 inches), 
with 496 wood-cuts in text, and 37 colored and half-tone plates, many of 
them engraved from original photographs and drawings furnished by the 
authors. Price : Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. 

THIRD EDITION. THOROUGHLY REVISED. 

In the present edition, among the new topics introduced are a full considera- 
tion of serum-therapy ; leucocytosis ; post-operative insanity; the use of dry heat 
at high temperatures ; Kronlein's method of locating the cerebral fissures ; 
Hoffa's and Lorenz's operations of congenital dislocations of the hip ; Allis's re- 
searches on dislocations of the hip-joint ; lumbar puncture ; the forcible reposi- 
tion of the spine in Pott's disease ; the treatment of exophthalmic goiter ; the 
surgery of typhoid fever ; gastrectomy and other operations on the stomach ; 
new methods of operating upon the intestines ; the use of Kelly's rectal specula ; 
the surgery of the ureter ; Schleich's infiltration-method and the use of eucain 
for local anesthesia ; Krause's method of skin-grafting ; the newer methods of 
disinfecting the hands ; the use of gloves, etc. The sections on Appendicitis, 
on Fractures, and on Gynecological Operations have been revised and enlarged. 
A considerable number of new illustrations have been added, and enhance the 
value of the work. 

The text of the entire book has been submitted to all the authors for their 
mutual criticism and revision — an idea in book-making that is entirely new and 
original. The book as a whole, therefore, expresses on all the important sur- 
gical topics of the day the consensus of opinion of the eminent surgeons who 
have joined in its preparation. 

One of the most attractive features of the book is its illustrations. Very 
many of them are original and faithful reproductions of photographs taken 
directly from patients or from specimens, 

CONTRIBUTORS: 



Phineas S. Conner, Cincinnati. 
Frederic S. Dennis, New York. 
William W. Keen, Philadelphia. 
Charles B. Nancrede, Ann Arbor, Mich. 
Roswell Park, Buffalo, New York. 
Lewis S. Pilcher. New York. 



Dr. Nicholas Senn, Chicago. 

Francis J. Shepherd, Montreal, Canada. 

Lewis A. Stimson, New York. 

J. Collins Warren, Boston. 

J. William White, Philadelphia. 



'• If this text-book is a fair reflex of the present position of American surgery, we must 
admit it is of a very high order of merit, and that English surgeons will have to look very 
carefullv to their laurels if they are to preserve a position in the van of surgical practice."— 
London Laticet. 

Personally, I should not mind it being called THE Text-Book (instead of A Text-Book), 
for I know ot no single volume which contains so readable and complete an account of the 
science and art of Surgery as this does."— Edmund Owen, F. R. C. S., Member of the Board 
tif Examiners of the Royal College of Surgeons, England; 



12 TV. B. SAUNDERS' 



*AN AMERICAN TEXT-BOOK OF GYNECOLOGY, MEDICAL 
AND SURGICAL, for the use of Students and Practitioners. 

Edited by J. M. Baldy, M. D. Forming a handsome royal-octavo volume 
of 718 pages, with 341 illustrations in the text and 38 colored and half- 
tone plates. Prices : Cloth, $6.00 net; Sheep or Half-Morocco, $7.00 net. 

SECOND EDITION, THOROUGHLY REVISED. 

In this volume all anatomical descriptions, excepting those essential to a clear 
understanding of the text, have been omitted, the illustrations being largely de- 
pended upon to elucidate the anatomy of the parts. This work, which is 
thoroughly practical in its teachings, is intended, as its title implies, to be a 
working text-book for physicians and students. A clear line of treatment has 
been laid down in every case, and although no attempt has been made to dis- 
cuss mooted points, still the most important of these have been noted and ex- 
plained. The operations recommended are fully illustrated, so that the reader, 
having a picture of the procedure described in the text under his eye, cannot fail 
to grasp the idea. All extraneous matter and discussions have been carefully 
excluded, the attempt being made to allow no unnecessary details to cumber 
the text. The subject-matter is brought up to date at every point, and the 
work is as nearly as possible the combined opinions of the ten specialists who 
figure as the authors. 

In the revised edition much new material has been added, and some of the 
old eliminated or modified. More than forty of the old illustrations have been 
replaced by new ones, which add very materially to the elucidation of the 
text, as they picture methods, not specimens. The chapters on technique and 
after-treatment have been considerably enlarged, and the portions devoted to 
plastic work have been so greatly improved as to be practically new. Hyste- 
rectomy has been rewritten, and all the descriptions of operative procedures 
have been carefully revised and fully illustrated. 



CONTRIBUTORS 



Dr. Henry T. Byford. 
John M. Baldy. 
Edwin Cragin. 
I. H. Etheridge. 
William Goodell. 



Dr. Howard A. Kelly. 
Florian Krug. 
E. E. Montgomery. 
William R. Pryor. 
George M. Tuttle. 



"The most notable contribution to gynecological literature since 1887, .... and the most 
complete exponent of gynecology which we have. No subject seems to have been neglected, 
.... and the gynecologist and surgeon, and the general practitioner who has any desire 
to practise diseases of women, will find it of practical value. In the matter of illustrations 
and plates the book surpasses anything we have seen." — Boston Medical and Surgical 
Journal. 

" A thoroughly modern text-book, and gives reliable and well-tempered advice and in- 
struction." — Edinburgh Medical Journal. 

" The harmony of its conclusions and the homogeneity of its style give it an individuality 
which suggests a single rather than a multiple authorship." — Annals of Surgery. 

" It must command attention and respect as a worthy representation of our advanced 
clinical teaching." — American Journal of Medical Sciences. 



CATALOGUE OF MEDICAL WORKS. 



13 



*AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHIL- 
DREN. By American Teachers. Edited by Louis Starr, M. D., 
assisted by Thompson S. Westcott, M. D. In one handsome reyal-8vr> 
volume of 1244 pages, profusely illustrated with wood-cuts, half-tone and 
colored plates. Net Prices : Cloth, $7.00; Sheep or Half-Morocco, $8.00. 

SECOND EDITION, REVISED AND ENLARGED. 

The plan of this work embraces a series of original articles written by some 
sixty well-known podiatrists, representing collectively the teachings of the most 
prominent medical schools and colleges of America. The work is intended to 
be a practical book, suitable for constant and handy reference by the practi- 
tioner and the advanced student. 

Especial attention has been given to the latest accepted teachings upon the 
etiology, symptoms, pathology, diagnosis, and treatment of the disorders of chil- 
dren, with the introduction of many special formulae and therapeutic procedures. 

In this new edition the whole subject matter has been carefully revised, new 
articles added, some original papers emended, and a number entirely rewritten. 
The new articles include " Modified Milk and Percentage Milk-Mixtures," 
" Lithemia," and'a section on " Orthopedics." Those rewritten are " Typhoid 
Fever," "Rubella," "Chicken-pox," "Tuberculous Meningitis," "Hydroceph- 
alus," and "Scurvy;" while extensive revision has been made in "Infant 
Feeding," " Measles," " Diphtheria," and " Cretinism." The volume has thus 
been much increased in size by the introduction of fresh material. 



CONTRIBUTORS t 

Dr. S. S. Adams, Washington. 

John Ashhurst, Jr., Philadelphia. 
A. D. Blackader, Montreal, Canada. 
David Bovaird. New York. 
Dillon Brown, New York. 
Edward M. Buckingham, Boston. 
Charles W. Burr, Philadelphia. 
W. E. Casselberry, Chicago. 
Henry Dwight Chapin, New York. 
W. S. Christopher, Chicago. 
Archibald Church, Chicago. 
Floyd M. Crandall, New York. 
Andrew F. Currier, New York. 
Roland G. Curtin, Philadelphia 
J. M. DaCosm, Philadelphia. 
I. N. Danforth, Chicago. 
Edward P. Davis, Philadelphia. 
John B. Deaver, Philadelphia. 
G. E. de Schweinitz, Philadelphia. 
John Doming, New York. 
Charles Warrington Earle, Chicago. 
Wm. A. Edwards, San Diego, Cal. 
F. Forchheimer, Cincinnati. 
J. Henry Fruitnight, New York. 
J. P. Crozer Griffith, Philadelphia. 
W. A. Hardaway. St. Louis. 
M. P Hatfield, Chicago. 
Barton Cooke Hirst, Philadelphia. 
H. Uloway, Cincinnati. 
Henry Jackson, Boston. 



Charles G. Jennings, Detroit. 
Henry Koplik, New York. 



Dr. Thomas S. Latimer, Baltimore. 
Albert R. Leeds, Hoboken, N. J. 
J. Hendrie Lloyd, Philadelphia. 
George Roe Lockwood, New York. 
Henry M. Lyman, Chicago. 
Francis T. Miles, Baltimore. 
Charles K Mills, Philadelphia. 
James E Moore, Minneapolis. 
F. Gordon Morrill, Boston. 
John H. Musser, Philadelphia. 
Thomas R. Neilson, Philadelphia. 
W. P. Northrup, New York. 
William Osier, Baltimore. 
Frederick A. Packard, Philadelphia. 
William Pepper, Philadelphia. 
Frederick Peterson, New York. 
W. T. Plant, Syracuse, New York. 
William M. Powell, Atlantic City. 
B. K. Rachford, Cincinnati. 
B. Alexander Randall, Philadelphia. 
Edward O. Shakespeare, Philadelphia 
F. C. Shattuck, Boston. 
J. Lewis Smith, New York. 
Louis Starr, Philadelphia. 
M. Allen Starr, New York. 
Charles W. Townsend, Boston. 
James Tyson, Philadelphia. 
W. S. Thayer, Baltimore. 
Victor C. Vaughan, Ann Arbor, Mich 
Thompson S. Westcott, Philadelphia. 
Henry R. Wharton, Philadelphia. 



J William White, Philadelphia. 
J. C. Wilson, Philadelphia. 



14 



W. B. SAUNDERS 



* AN AMERICAN TEXT-BOOK OF GENITO-URINARY AND 
SKIN DISEASES. By 47 Eminent Specialists and Teachers. Edited 
by L. Bolton Bangs, M. D., Professor of Genito-Urinary Surgery, Uni- 
versity and Bellevue Hospital Medical College, New York ; and W. A. 
Hardaway, M. D., Professor of Diseases of the Skin, Missouri Medical 
College. Imperial octavo volume of 1229 pages, with 300 engravings and 
20 full-page colored plates. Cloth, $7.00 net ; Sheep or Half Morocco, 
$8.00 net. 

This addition to the series of " American Text-Books," it is confidently be- 
lieved, will meet the requirements of both students and practitioners, giving, as 
it does, a comprehensive and detailed presentation of the Diseases of the 
Genito-Urinary Organs, of the Venereal Diseases, and of the Affections of the 
Skin. 

Having secured the collaboration of well-known authorities in the branches 
represented in the undertaking, the editors have not restricted the contributors 
in regard to the particular views set forth, but have offered every facility for the 
free expression of their individual opinions. The work will therefore be found 
to be original, yet homogeneous and fully representative of the several depart- 
ments of medical science with which it is concerned. 



CONTRIBUTORS s 



Dr. Chas. W. Allen, New York. 
I. E. Atkinson, Baltimore. 
L Bolton Bangs, New York. 
P. R. Bolton, New York. 
Lewis C. Bosher, Richmond, Va. 
John T. Bowen, Boston. 
J. Abbott Cantrell. Philadelphia. 
William T. Corlett, Cleveland, Ohio. 
B. Farquhar Curtis, New York. 
Condict W. Cutler, New York. 
Isadore Dyer, New Orleans. 
Christian Fenger, Chicago. 
John A. Fordyce, New York. 
Eugene Fuller, New York. 
R. H. Greene, New York. 
Joseph Orindon, St. Louis. 
Graeme M. Hammond, New York. 
W. A. Hardaway, St. Louis. 
M. B. Hartzell, Philadelphia. 
Louis Heitzmann, New York. 
James S. Howe, Boston. 
George T. Jackson, New York. 
Abraham Jacobi, New York. 
James C. Johnston. New York. 



Dr. Hermann G. Klotz, New York. 
J. H. Linsley, Burlington, V't. 
G. F. Lydston, Chicago. 
Hartwell N. Lyon, St. Louis. 
Edward Martin, Philadelphia. 
D. G. Montgomery, San Francisco. 
James Pedersen, New York. 
S. Pollitzer, New York. 
Thomas R. Pooley, New York. 
A. R. Robinson, New York. 
A. E. Regensburger, San Francisco, 
Francis J. Shepherd, Montreal, Can. 
S. C. Stanton, Chicago, 111. 
Emmanuel J. Stout, Philadelphia. 
Alonzo E. Taylor, Philadelphia. 
Robert W. Taylor, New York. 
Paul Thorndike, Boston. 
H. Tuholske, St. Louis. 
Arthur Van Harlingen, Philadelphia. 
Francis S. Watson, Boston. 
J. William White, Philadelphia. 
J. McF. Winfield, Brooklyn. 
Alfred C. Wood, Philadeipma. 



"This voluminous work is thoroughly up to date, and the chapters on gemto-unnary dis- 
eases are especially valuable. The illustrations are fine and are mostly original. The section 
on dermatology is concise and in every way admirable."— Journal of the American Medical 
Association. 

" This volume is one of the best yet issued of the publisher's series of * American Text- 
Books.' The list of contributors represents an extraordinary array of talent and extended 
experience. The book will easily take the place in comprehensiveness and value of the 
half dozen or more costly works on these subjects which have hitherto been necessary to a 
well-equipped library." — New York Polyclinic. 



CATALOGUE OF MEDICAL WORKS. 



15 



* AN AMERICAN TEXT-BOOK OF DISEASES OF THE EYE, 
EAR, NOSE, AND THROAT. Edited by George E. de Schweinitz, 

A. M., M. D., Professor of Ophthalmology, Jefferson Medical College; and 

B. Alexander Randall, A. M., M. D., Clinical Professor of Diseases of 
the Ear, University of Pennsylvania. One handsome imperial octavo 
volume of 1251 pages; 766 illustrations, 59 of them colored. Prices: 
Cloth, $7.00 net; Sheep or Half-Morocco, $8.00 net. 

Just Issued, 

The present work is the only book ever published embracing diseases of the 
intimately related organs of the eye, ear, nose, and throat. Its special claim 
to favor is based on encyclopedic, authoritative, and practical treatment of the 
subjects. 

Each section of the book has been entrusted to an author who is specially 
identified with the subject on which he writes, and who therefore presents his 
case in the manner of an expert. Uniformity is secured and overlapping pre- 
vented by careful editing and by a system of cross-references which forms a 
special feature of the volume, enabling the reader to come into touch with all 
that is said on any subject in different portions of the book. 

Particular emphasis is laid on the most approved methods of treatment, so 
that the book shall be one to which the student and practitioner can refer for 
information in practical work. Anatomical and physiological problems, also, 
are fully discussed for the benefit of those who desire to investigate the more 
abstruse problems of the subject. 



CONTRIBUTORS : 



Dr. Henry A. Alderton, Brooklyn. 
Harrison Allen, Philadelphia. 
Frank Allport, Chicago. 
Morris J. Asch, New York. 
S. C. Ayres, Cincinnati. 
R. O. Beard, Minneapolis. 
Clarence J. Blake, Boston. 
Arthur A- Bliss, Philadelphia. 
Albert P. Brubaker, Philadelphia. 
J. H. Bryan, Washington, D. C. 
Albert H. Buck, New York. 
F. Buller, Montreal, Can. 
Swan M. Burnett, Washington, D. C. 
Flemming Carrow, Ann Arbor, Mich. 
W. E. Casselberry, Chicago. 
Colman W. Cutler, New York. 
Edward B. Dench, New York. 
William S. Dennett, New York. 
George E. de Schweinitz, Philadelphia. 
Alexander Duane, New York. 
John W. Farlow, Boston, Mass. 
Walter J. Freeman, Philadelphia. 
H. Gifford, Omaha, Neb. 
W. C. Glasgow, St. Louis. 
J. Orne Green, Boston. 
Ward A. Holden, New York. 
Christian R. Holmes, Cincinnati. 
William E. Hopkins, San Francisco. 
F. C. Hotz, Chicago. 
Lucien Howe, Buffalo, N. Y. 



Dr. Alvin A. Hubbell, Buffalo, N. Y. 
Edward Jackson, Philadelphia. 
J. Ellis Jennings, St. Louis. 
Herman Knapp, New York. 
Chas. W. Kollock, Charleston, S. C. 
G. A. Leland, Boston. 
J. A. Lippincott, Pittsburg, Pa. 
G. Hudson Makuen, Philadelphia. 
John H. McCollom, Boston. 
H. G. Miller, Providence, R. I. 
B. L. Miliiken, Cleveland, Ohio. 
Robert C. Myles, New York. 
James E. Newcomb, New York. 
R. J. Phiilips, Philadelphia. 
George A. Piersol, Philadelphia. 
W. P. Porcher, Charleston, S. C. 
B. Alex. Randall, Philadelphia. 
Robert L. Randolph, Baltimore. 
John O. Roe, Rochester, N. Y. 
Charles E. de M. Sajous, Philadelphia. 
J. E. Sheppard, Brooklyn, N. Y. 
E. L. Shurly, Detroit, Mich. 
William M. Sweet, Philadelphia. 
Samuel Theobald, Baltimore, Md. 
A. G. Thomson, Philadelphia. 
Clarence A. Veasey, Philadelphia. 
John E. Weeks, New York. 
Casey A. Wood, Chicago, 111. 
Jonathan Wright, Brooklyn. 
H. V. Wiirdemann, Milwaukee, Wis. 



i6 



W. B. SAUNDERS' 



*AN AMERICAN YEAR-BOOK OF MEDICINE AND SUR- 
GERY. A Yearly Digest of Scientific Progress and Authoritative 
Opinion in all branches of Medicine and Surgery, drawn from journals) 
monographs, and text-books of the leading American and Foreign authors 
and investigators. Collected and arranged, with critical editorial com- 
ments, by eminent American specialists and teachers, under the general 
editorial charge of George M. Gould, M. D. Volumes for 1896, '97, 
'98, and '99 each a handsome imperial octavo volume of about 1200 pages. 
Prices : Cloth, $6.50 net ; Half-Morocco, $7.50 net. Year-Book for 1900 in 
two octavo volumes of about 600 pages each. Prices per volume : Cloth, 
$3.00 net; Half-Morocco, $3.75 net. 

In Two Volumes. No Increase in Price. 

In response to a widespread demand from the medical profession, the pub- 
lisher of the "American Year-Book of Medicine and Surgery" has decided to 
issue that well-known work in two volumes, Vol. I. treating of General Medi- 
cine, Vol. II. of General Surgery. Each volume is complete in itself, and 
the work is sold either separately or in sets. 

This division is made in such a way as to appeal to physicians from a class 
standpoint, one volume being distinctly medical, and the other distinctly surgi- 
cal. This arrangement has a two-fold advantage. To the physician who uses 
the entire book, it offers an increased amount of matter in the most convenient 
form for easy consultation, and without any increase in price ; while the man 
who wants either the medical or the surgical section alone secures the complete 
consideration of his branch without the necessity of purchasing matter for which 
he has no use. 

CONTRIBUTORS : 



Vol. I. 
Samuel W. Abbott. Boston. 
Archibald Church, Chicago. 
Louis A. Duhring, Philadelphia. 
D. L. Edsall, Philadelphia. 
Alfred Hand, Jr., Philadelphia. 
M. B. Hartzell, Philadelphia. 
Reid Hunt, Baltimore. 
Wyatt Johnston, Montreal. 
Walter Jones, Baltimore. 
David Riesman, Philadelphia. 
Louis Starr, Philadelphia. 
Alfred Stengel, Philadelphia. 
A. A. Stevens, Philadelphia. 
G. N. Stewart. Cleveland. 
Reynold W. Wilcox, New York City. 



Vol. II. 
Dr. J. Montgomery Baldy, Philadelphia. 
Charles H. Burnett, Philadelphia. 
J. Chalmers DaCosta. Philadelphia. 
W. A. N. Dorland, Philadelphia. 
Virgil P. Gibney, New York City. 
C. H. Hamann, Cleveland. 
Howard F. Hansell, Philadelphia. 
Barton Cooke Hirst, Philadelphia. 
E. Fletcher lngals, Chicago. 
W. W. Keen, Philadelphia. 
Henry G. Ohls, Chicago. 
Wendell Reber, Philadelphia. 
J. Hilton Waterman, New York City. 



" It is difficult to know which to admire most— the research and industry of the distin- 
guished band of experts whom Dr. Gould has enlisted in the service of the Year-Book, or the 
wealth and abundance of the contributions to every department of science that have been 
deemed worthy of analysis. ... It is much more than a mere compilation of abstracts, for, 
as each section is entrusted to experienced and able contributors, the reader has the advan- 
tage of certain critical commentaries and expositions . . . proceeding from writers fully 
qualified to perform these tasks. ... It is emphatically a book which should find a place in 
every medical library, and is in several respects more useful than the famous ' Jahrbucher ' 
of Germany." — London Lancet. 



CATALOGUE OF MEDICAL WORKS. \J 

* ANOMALIES AND CURIOSITIES OF MEDICINE. By George 
M. Gould, M.D., and Walter L. Pyle, M.D. An encyclopedic collec- 
tion of are and extraordinary cases and of the most striking instances of 
abnormality in all branches of Medicine and Surgery, derived from an ex- 
haustive research of medical literature from its origin to the present day, 
abstracted, classified, annotated, and indexed. Handsome imperial octavo 
volume of 968 pages, with 295 engravings in the text, and 12 full-page 
plates. Cloth, $3.00 net; Half-Morocco, $4.00 net. 

POPULAR EDITION REDUCED FROM $6.00 to $3.00. 

In view of the great success of this magnificent work, the publisher has decided 
to issue a " Popular Edition " at a price so low that it may be procured by every 
student and practitioner of medicine. Notwithstanding the great reduction in 
price, there will be no depreciation in the excellence of typography, paper, and 
binding that characterized the earlier editions. 

Several years of exhaustive research have been spent by the authors in the 
great medical libraries of the United States and Europe in collecting the mate- 
rial for this work. Medical literature of all ages and all languages has 
been carefully searched, as a glance at the Bibliographic Index will show. The 
facts, which will be of extreme value to the author and lecturer, have been 
arranged and annotated, and full reference footnotes given. 

"One of the most valuable contributions ever made to medical literature. It is, so far as 
we know, absolutely unique, and every page is as fascinating as a novel. Not alone for the 
medical profession has this volume value : it will serve as a book of reference for all who are 
interested in general scientific, sociologic, or medico-legal topics." — Brooklyn Medical Jour- 
nal. 



NERVOUS AND MENTAL DISEASES. By Archibald Church, 
M. D., Professor of Clinical Neurology, Mental Diseases, and Medical 
Jurisprudence, Northwestern University Medical School ; and Frederick 
Peterson, M. D., Clinical Professor of Mental Diseases, Woman's Medi- 
cal College, New York. Handsome octavo volume of 843 pages, with 
over 300 illustrations. Prices: Cloth, $5.00 net; Half- Morocco, $6.00 
net. 

Second Edition, 

This book is intended to furnish students and practitioners with a practical, 
working knowledge of nervous and mental diseases. Written by men of wide 
experience and authority, it presents the many recent additions to the subject. 
The book is not filled with an extended dissertation on anatomy and pathology, 
but, treating these points in connection with special conditions, it lays particular 
stress on methods of examination, diagnosis, and treatment. In this respect the 
work is unusually complete and valuable, laying down the definite courses of 
procedure which the authors have found to be most generally satisfactory. 

" The work is an epitome of what is to-day known of nervous diseases prepared for the 
student and practitioner in the light of the author's experience . . . We believe that no work 
presents the difficult subject of insanity in such a reasonable and readable way." — Chicago 
Medical Recorder. 



1 8 W. B. SAUNDERS' 



DISEASES OF THE NOSE AND THROAT. By D. Braden Kyle, 
M. D., Clinical Professor of Laryngology and Rhinology, Jefferson Medi- 
cal College, Philadelphia; Consulting Laryngologist, Rhinologist, and 
Otologist, St. Agnes' Hospital. Octavo volume of 646 pages, with over 
150 illustrations and 6 lithographic plates. Cloth, $4.00 net; Half-Mo- 
rocco, $5.00 net. 

Just Issued, 

This book presents the subject of Diseases of the Nose and Throat in as con- 
cise a manner as is consistent with clearness, keeping in mind the needs of the 
student and general practitioner as well as those of the specialist. The arrange- 
ment and classification are based on modern pathology, and the pathological 
views advanced are supported by drawings of microscopical sections made in the 
author's own laboratory. These and the other illustrations are particularly fine, 
being chiefly original. With the practical purpose of the book in mind, ex- 
tended consideration has been given to details of treatment, each disease being 
considered in full, and definite courses being laid down to meet special condi- 
tions and symptoms. 

" It is a thorough, full, and systematic treatise, so classified and arranged as greatly to facili- 
tate the teaching of laryngology and rhinology to classes, and must prove most convenient 
and satisfactory as a reference book, both for students and practitioners." — International 
Medical Magazine. 

THE HYGIENE OF TRANSMISSIBLE DISEASES : their Causa- 
tion, Modes of Dissemination, and Methods of Prevention. By 
A. C. Abbott, M. D., Professor of Hygiene in the University of Pennsyl- 
vania; Director of the Laboratory of Hygiene. Octavo volume of 31 1 
pages, with charts and maps, and numerous illustrations. Cloth, $2.00 net. 



Just Issued, 

It is not the purpose of this work to present the subject of Hygiene in the 
comprehensive sense ordinarily implied by the word, but rather to deal directly 
with but a section, certainly not the least important, of the subject— viz., that 
embracing a knowledge of the preventable specific diseases. The book aims to 
furnish information concerning the detailed management of transmissible dis- 
eases. Incidentally there are discussed those numerous and varied factors that 
have not only a direct bearing upon the incidence and suppression of such dis- 
eases, but are of general sanitary importance as well. 

" The work is admirable in conception and no less so in execution. It is a practical work, 
simply and lucidly written, and it should prove a most helpful aid in that department of 
medicine which is becoming daily of increasing importance and application — namely, prophy- 
laxis." — Philadelphia Medical Journal. 

" It is scientific, but not too technical; it is as complete as our present-day knowledge of 
hygiene and sanitation allows, and it is in harmony with the efforts of the profession, which 
are tending more and more to methods of prophylaxis. For the student and for the practi- 
tioner it is well nigh indispensable." — Medical News, New York. 



CATALOGUE OF MEDICAL WORKS. 1 9 

A TEXT-BOOK OF EMBRYOLOGY. By John C. Heisler, M. D. : 
Professor of Anatomy in the Medico- Chirurgical College, Philadelphia. 
Octavo volume of 405 pages, with 190 illustrations, 26 in colors. Cloth, 
$2.50 net. 

Just Issued. 

The facts of embryology having acquired in recent years such great interesl 
in connection with the teaching and with the proper comprehension of human 
anatomy, it is of first importance to the student of medicine that a concise and 
yet sufficiently full text-book upon the subject be available. It was with the 
aim of presenting such a book that this volume was written, the author, in his 
experience as a teacher of anatomy, having been impressed with the fact that 
students were seriously handicapped in their study of the subject of embryology 
by the lack of a text-book full enough to be intelligible, and yet without that 
minuteness of detail which characterizes the larger treatises, and which so often 
serves only to confuse and discourage the beginner. 

" In short, the book is written to fill a want which has distinctly existed and which it 
definitely meets ; commendation greater than this it is not possible to give to anything." — 
Medical News, New York. 

A MANUAL OF DISEASES OF THE EYE. By Edward Jack- 
son, A. M., M. D., sometime Professor of Diseases of the Eye in the Phila- 
delphia Polyclinic and College for Graduates in Medicine. i2mo, 604 
pages, with 178 illustrations from drawings by the author. Cloth, $2.50 net. 

Just Issued, 

This book is intended to meet the needs of the general practitioner of medi- 
cine and the beginner in ophthalmology. More attention is given to the condi- 
tions that must be met and dealt with early in ophthalmic practice than to the 
rarer diseases and more difficult operations that may come later. 

It is designed to furnish efficient aid in the actual work of dealing with dis- 
ease, and therefore gives the place of first importance to the recognition and 
management of the conditions that present themselves in actual clinical work. 

LECTURES ON THE PRINCIPLES OF SURGERY. By Charles 
B. Nancrede, M. D., LL.D., Professor of Surgery and of Clinical Surgery, 
University of Michigan, Ann Arbor. Handsome octavo, 398 pages, illus- 
trated. Cloth, $2.50 net. 

Just Issued. 

The present book is based on the lectures delivered by Dr. Nancrede to his 
undergraduate classes, and is intended as a text-book for students and a practi- 
cal help for teachers. By the careful elimination of unnecessary details of 
pathology, bacteriology, etc., which are amply provided for in other courses of 
study, space is gained for a more extended consideration of the Principles of 
Surgery in themselves, and of the application of these principles to methods 
of practice. 



20 W. B. SAUNDERS' 



A TEXT-BOOK OF PATHOLOGY. By Alfred Stengel, M. D., 
Professor of Clinical Medicine in the University of Pennsylvania; Physi- 
cian to the Philadelphia Hospital ; Physician to the Children's Hospital, 
Philadelphia. Handsome octavo volume of 848 pages, with 362 illustra- 
tions, many of which are in colors. Prices : Cloth, $4.00 net ; Half- 
Morocco, $5.00 net. 

Second Edition. 

In this work the practical application of pathological facts to clinical medicine 
is considered more fully than is customary in works on pathology. While the 
subject of pathology is treated in the broadest way consistent with the size of 
the book, an effort has been made to present the subject from the point of view 
of the clinician. The general relations of bacteriology to pathology are dis- 
cussed at considerable length, as the importance of these branches deserves. It 
will be found that the recent knowledge is fully considered, as well as older and 
more widely-known facts. 

" I consider the work abreast of modern pathology, and useful to both students and prac- 
titioners. It presents in a concise and well-considered form the essential facts of general and 
special pathological anatomy, with more than usual emphasis upon pathological physiology." 
— William H. Welch, Professor 0/ Pathology, Johns Hopkins University, Baltimore, Md. 

" I regard it as the most serviceable text-book for students on this subject yet written by 
an American author."— L. Hektoen, Professor of Pathology, Rush Medical College, 
Chicago, III. 

A TEXT-BOOK OF OBSTETRICS. By Barton Cooke Hirst, M.D., 
Professor of Obstetrics in the University of Pennsylvania. Handsome oc- 
tavo volume of 846 pages, with 618 illustrations and seven colored plates. 
Prices : Cloth, $5.00 net ; Half-Morocco, $6.00 net. 

Second Edition, 

This work, which has been in course of preparation for several years, is in- 
tended as an ideal text-book for the student no less than an advanced treatise 
for the obstetrician and for general practitioners. It represents the very latest 
teaching in the- practice of obstetrics by a man of extended experience and 
recognized authority. The book emphasizes especially, as a work on obstetrics 
should, the practical side of the subject, and to this end presents an unusually 
large collection of illustrations. A great number of these are new and original, 
and the whole collection will form a complete atlas of obstetrical practice. 
An extremely valuable feature of the book is the large number of refer- 
ences to cases, authorities, sources, etc., forming, as it does, a valuable bib- 
liography of the most recent and authoritative literature on the subject 
of obstetrics. As already stated, this work records the wide practical ex- 
perience of the author, which fact, combined with the brilliant presentation 
of the subject, will doubtless render this one of the most notable books on 
obstetrics that has yet appeared. 

" The illustrations are numerous and are works of art, many of them appearing for the 
first time. The arrangement of the subject-matter, the foot-notes, and index are beyond 
criticism. The author's style, though condensed, is singularly clear, so that it is never 
necessary to re-read a sentence in order to grasp its meaning. As a true model of what a 
modern text-book in obstetrics should be, we feel justified in affirming that Dr. Hirst's 
book is without a rival." — New York Medical Record. 



CATALOGUE OF MEDICAL WORKS. 21 

A TEXT-BOOK OF THE PRACTICE OF MEDICINE. . By 

James M. Anders, M.D., Ph.D., LL.D., Professor of the Practice of 
Medicine and of Clinical Medicine, Medico-Chirurgical College, Philadel- 
phia. In one handsome octavo volume of 1292 pages, fully illustrated. 
Cloth, #5.50 net; Sheep or Half-Morocco, $6.50 net. 

THIRD EDITION, THOROUGHLY REVISED. 

The present edition is the result of a careful and thorough revision. A few 
new subjects have been introduced : Glandular Fever, Ether-pneumonia, Splenic 
Anemia, Meralgia Paresthetica, and Periodic Paralysis. The affections that 
have been substantially rewritten are: Plague, Malta Fever, Diseases of the 
Thymus Gland, Liver Cirrhoses, and Progressive Spinal Muscular Atrophy. 
The following articles have been extensively revised : Typhoid Fever, Yellow 
Fever, Lobar Pneumonia, Dengue, Tuberculosis, Diabetes Mellitus, Gout, Ar- 
thritis Deformans, Autumnal Catarrh, Diseases of the Circulatory System, more 
particularly Hypertrophy and Dilatation of the Heart, Arteriosclerosis and 
Thoracic Aneurysm, Pancreatic Hemorrhage, Jaundice, Acute Peritonitis, Acute 
Yellow Atrophy, Hematoma of Dura Mater, and Scleroses of the Brain. The 
preliminary chapter on Nervous Diseases is new, and deals with the subject of 
localization and the various methods of investigating nervous affections. 

"It is an excellent book — concise,- comprehensive, thorough, and up to date. It is a 
credit to you; but, more than that, it is a credit to the profession of Philadelphia— to us." 
— James C. Wilson, Professor of the Practice of Medicine and Clinical Medicine, Jeffer- 
son Medical College, Philadelphia. 

" The book can be unreservedly recommended to students and practitioners as a safe, full 
compendium of the knowledge of internal medicine of the present day ... It is a work 
thoroughly modern in every sense." — Medical News, New York. 

DISEASES OF THE STOMACH. By William W. Van Valzah, 

M. D., Professor of General Medicine and Diseases of the Digestive System 
and the Blood, New York Polyclinic ; and J. Douglas Nisbet, M. D., 
Adjunct Professor of General Medicine and Diseases of the Digestive Sys- 
tem and the Blood, New York Polyclinic. Octavo volume of 674 pages, 
illustrated. Cloth, $3.50 net. 

An eminently practical book, intended as a guide to the student, an aid to the 
physician, and a contribution to scientific medicine. It aims to give a complete 
description of the modern methods of diagnosis and treatment of diseases of the 
stomach, and to reconstruct the pathology of the stomach in keeping with the 
revelations of scientific research. The book is clear, practical, and complete, 
and contains the results of the authors' investigations and of their extensive ex- 
perience as specialists. Particular attention is given to the important subject of 
dietetic treatment. The diet-lists are very complete, and are so arranged that 
selections can readily be made to suit individual cases. 

" This is the most satisfactory work on the subject in the English language." — Chicago 
Medical Recorder. 

" The article on diet and general medication is one of the most valuable in the book, and 
should be read by every practising physician." — New York Medical Journal. 



22 W. B. SAUNDERS' 



SURGICAL DIAGNOSIS AND TREATMENT. By J. W. Mao 

donald, M. D., Edin., F. R. C.S., Edin., Professor of the Practice of Sur- 
gery and of Clinical Surgery in Hamline University ; Visiting Surgeon to St. 
Barnabas' Hospital, Minneapolis, etc. Handsome octavo volume of 800 
pages, profusely illustrated. Cloth, $5.00 net; Half-Morocco, $6.00 net. 
This work aims in a comprehensive manner to furnish a guide in matters of 
surgical diagnosis. It sets forth in a systematic way the necessities of examina- 
tions and the proper methods of making them. The various portions of the 
body are then taken up in order and the diseases and injuries thereof succinctly 
considered and the treatment briefly indicated. Practically all the modern and 
approved operations are described with thoroughness and clearness. The work 
concludes with a chapter on the use of the Rontgen rays in surgery. 

" The work is brimful of just the kind of practical information that is useful alike to 
students and practitioners. It is a pleasure to commend the book because of its intrinsic 
value to the medical practitioner." — Cincinnati Lancet- Clinic. 

PATHOLOGICAL TECHNIQUE. A Practical Manual for Laboratory 
Work in Pathology, Bacteriology, and Morbid Anatomy, with chapters on 
Post-Mortem Technique and the Performance of Autopsies. By Frank 
B. Mallory, A. M., M. D., Assistant Professor of Pathology, Harvard 
University Medical School, Boston; and James H. Wright, A. M., M.D., 
Instructor in Pathology, Harvard University Medical School, Boston. Oc- 
tavo volume of 396 pages, handsomely illustrated. Cloth, $2.50 net. 
This book is designed especially for practical use in pathological laboratories, 
both as a guide to beginners and as a source of reference for the advanced. The 
book will also meet the wants of practitioners who have opportunity to do general 
pathological work. Besides the methods of post-mortem examinations and of 
bacteriological and histological investigations connected with autopsies, the 
special methods employed in clinical bacteriology and pathology have been 
fully discussed. 

" One of the most complete works on the subject, and one which should be in the library 
of every physician who hopes to keep pace with the great advances made in pathology." — 
Journal of American Medical Association. 

THE SURGICAL COMPLICATIONS AND SEQUELS OF TY- 
PHOID FEVER. By Wm. W. Keen, M. D., LL.D., Professor of the 
Principles of Surgery and of Clinical Surgery, Jefferson Medical College, 
Philadelphia. Octavo volume of 386 pages, illustrated. Cloth, $3.00 net. 
This monograph is the only one in any language covering the entire subject 
of the Surgical Complications and Sequels of Typhoid Fever. The work will 
prove to be of importance and interest not only to the general surgeon and phy- 
sician, but also to many specialists — laryngologists, ophthalmologists, gynecolo- 
gists, pathologists, and bacteriologists — as the subject has an important bearing 
upon each one of their spheres. The author's conclusions are based on reports 
of over 1700 cases, including practically all those recorded in the last fifty years. 
Reports of cases have been brought down to date, many having been added 
while the work was in press. 

" This is probably the first and only work in the English language that gives the reader a 
clear view of what typhoid fever really is, and what it does and can do to the human organ- 
ism. This book should be in the possession of every medical man in America." — American 
Medico-Surgical Bulletin. 



CATALOGUE OF MEDICAL WORKS. 23 

MODERN SURGERY, GENERAL AND OPERATIVE. By John 
Chalmers DaCosta, M.D., Clinical Professor of Surgery, Jefferson Medi- 
cal College, Philadelphia; Surgeon to the Philadelphia Hospital, etc. 
Handsome octavo volume of 911 pages, profusely illustrated. Cloth, $4.00 
net; Half-Morocco, $5.00 net. 

Second Edition, Rewritten and Greatly Enlarged, 

The remarkable success attending DaCosta's Manual of Surgery, and the 
general favor with which it has been received, have led the author in this 
revision to produce a complete treatise on modern surgery along the same lines 
that made the former edition so successful. The book has been entirely re- 
written and very much enlarged. The old edition has long been a favorite not 
only with students and teachers, but also with practising physicians and sur- 
geons, and it is believed that the present work will find an even wider field of 
usefulness. 

"We know of no small work on surgery in the English language which so well fulfils the 
requirements of the modern student." — Medico-Chirurgical Journal, Bristol, England. 

" The author has presented concisely and accurately the principles of modern surgery. 
The book is a valuable one which can be recommended to students and is of great value to 
the general practitioner." — American Journal oj the Medical Sciences. 

A MANUAL OF ORTHOPEDIC SURGERY. By James E. Moore, 
M.D., Professor of Orthopedics and Adjunct Professor of Clinical Surgery, 
University of Minnesota, College of Medicine and Surgery. Octavo volume 
of 356 pages, with 177 beautiful illustrations from photographs made spec- 
ially for this work. Cloth, $2.50 net. 

A practical book based upon the author's experience, in which special stress 
is laid upon early diagnosis and treatment such as can be carried out by the 
general practitioner. The teachings of the author are in accordance with his 
belief that true conservatism is to be found in the middle course between the 
surgeon who operates too frequently and the orthopedist who seldom operates. 

"A very demonstrative work, every illustration of which conveys a lesson. The work is 
a most excellent and commendable one, which we can certainly endorse with pleasure." — 
St. Louis Medical and Stirgical Journal. 

ELEMENTARY BANDAGING AND SURGICAL DRESSING. 

With Directions concerning the Immediate Treatment of Cases of Emer- 
gency. For the use of Dressers and Nurses. By Walter Pye, F.R.C.S., 
late Surgeon to St. Mary's Hospital, London. Small i2mo, with over 80 
illustrations. Cloth, flexible covers, 75 cents net. 

This little book is chiefly a condensation of those portions of Pye's " Surgical 
Handicraft" which deal with bandaging, splinting, etc., and of those which 
treat of the management in the first instance of cases of emergency. The 
directions given are thoroughly practical, and the book will prove extremely use- 
ful to students, surgical nurses, and dressers. 

"The author writes well, the diagrams are clear, and the book itself is small and portable, 
although the paper and type are good." — British Medical Journal. 



24 W. B. SAUNDERS' 



A TEXT-BOOK OF MATERIA MEDICA, THERAPEUTICS 
AND PHARMACOLOGY. By George F. Butler, Ph.G., M.D., 
Professor of Materia Medica and of Clinical Medicine in the College of 
Physicians and Surgeons, Chicago; Professor of Materia Medica and 
Therapeutics, Northwestern University, Woman's Medical School, etc. 
Octavo, 874 pages, illustrated. Cloth, $4.00 net ; Sheep, $5.00 net. 
Third Edition, Thoroughly Revised, 
A clear, concise, and practical text-book, adapted for permanent reference no 
less than for the requirements of the class-room. 

The recent important additions made to our knowledge of the physiological 
action of drugs are fully discussed in the present edition. The book has been 
thoroughly revised and many additions have been made. 

" Taken as a whole, the book may fairly be considered as one of the most satisfactory of any 
single-volume works on materia medica in the market."— Journal of the American Medical 
Association. 

TUBERCULOSIS OF THE GENITO-URINARY ORGANS, 
MALE AND FEMALE. By Nicholas Senn, M.D., Ph.D., LL.D., 
Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical 
College, Chicago. Handsome octavo volume of 320 pages, illustrated. 
Cloth, $3.00 net. 

Tuberculosis of the male and female genito-urinary organs is such a frequent, 
distressing, and fatal affection that a special treatise on the subject appears to 
fill a gap in medical literature. In the present work the bacteriology of the sub- 
ject has received due attention, the modern resources employed in the differen- 
tial diagnosis between tubercular and other inflammatory affections are fully 
described, and the medical and surgical therapeutics are discussed in detail. 

"An important book upon an important subject, and written by a man of mature judg- 
ment and wide experience. The author has given us an instructive book upon one of the 
most important subjects of the day." — Clinical Reporter. 

" A work which adds another to the many obligations the profession owes the talented 
author." — Chicago Medical Recorder. 

A TEXT-BOOK OF DISEASES OF WOMEN. By Charles B. 
Penrose, M.D., Ph.D., Professor of Gynecology in the University of 
Pennsylvania; Surgeon to the Gynecean Hospital, Philadelphia. Octavo 
volume of 531 pages, with 217 illustrations, nearly all from drawings made 
for this work. Cloth, $3.75 net. 

Third Edition, Revised. 
In this work, which has been written for both the student of gynecology and 
the general practitioner, the author presents the best teaching of modern gyne- 
cology untrammelled by antiquated theories or methods of treatment. In most 
instances but one plan of- treatment is recommended, to avoid confusing the 
student or the physician who consults the book for practical guidance. 

"I shall value very highly the copy of Penrose's ' Diseases of Women' received. I have 
already recommended it to my class as THE BEST book." — Howard A. Kelly, Professor 
of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Md. 

" The book is to be commended without reserve, not only to the student but to the general 
practitioner who wishes to have the latest and best modes of treatment explained with absolute 
clearness." — Therapeutic Gazette. 



CATALOGUE OF MEDICAL WORKS. 25 



SURGICAL PATHOLOGY AND THERAPEUTICS. By John 
Collins Warren, M. D., LL.D., Professor of Surgery, Medical Depart- 
ment Harvard University. Handsome octavo, 832 pages, with 136 relief 
and lithographic illustrations, 33 of which are printed in colors. 

Second Edition, 

with an Appendix devoted to the Scientific Aids to Surgical Diagnosis, and 
a series of articles on Regional Bacteriology. Cloth, $5.00 net; Half- 
Morocco, $6.00 net. 

Without Exception, the Illustrations are the Best ever Seen in a 
Work of this Kind. 

"A most striking and very excellent feature of this book is its illustrations. Without ex- 
ception, from the point of accuracy and artistic merit, they are the best ever seen in a work 
of this kind. * * * Many of those representing microscopic pictures are so perfect in their 
coloring and detail as almost to give the beholder the impression that he is looking down the 
barrel of a microscope at a well-mounted section." — Annals of Surgery, Philadelphia. 

" It is the handsomest specimen of book-making * * * that has ever been issued from the 
American medical press." — American Journal of the Medical Sciences, Philadelphia. 

PATHOLOGY AND SURGICAL TREATMENT OF TUMORS. 

By N. Senn, M. D., Ph. D., LL. D., Professor of Practice of Surgery and 
of Clinical Surgery, Rush Medical College; Professor of Surgery, Chicago 
Polyclinic ; Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, 
St. Joseph's Hospital, Chicago. One volume of 710 pages, with 515 
engravings, including full-page colored plates. New and enlarged Edition 
in Preparation. 

Books specially devoted to this subject are few, and in our text-books and 
systems of surgery this part of surgical pathology is usually condensed to a de- 
gree incompatible with its scientific and clinical importance. The author spent 
many years in collecting the material for this work, and has taken great pains 
to present it in a manner that should prove useful as a text-book for the student, 
a work of reference for the practitioner, and a reliable guide for the surgeon. 

" The most exhaustive of any recent book in English on this subject. It is well illus- 
trated, and will doubtless remain as the principal monograph on the subject in our language 
for some years. The book is handsomely illustrated and printed, .... and the author has 
given a notable and lasting contribution to surgery." — Journal of the American Medical 
Association, Chicago. 

LECTURES ON RENAL AND URINARY DISEASES. By 

Robert Saundby, M. D., Edin., Fellow of the Royal College of Physicians, 
London, and of the Royal Medico-Chirurgical Society; Physician to the 
General Hospital. Octavo volume of 434 pages, with numerous illustra- 
tions and 4 colored plates. Cloth, $2.50 net. 

" The volume makes a favorable impression at once. The style is clear and succinct. 
We cannot find any part of the subject in which the views expressed are not carefully thought 
out and fortified by evidence drawn from the most recent sources. The book may be cordially 
recommended." — British Medical Journal. 



26 W. B. SAUNDERS' 



A NEW PRONOUNCING DICTIONARY OF MEDICINE, with 
Phonetic Pronunciation, Accentuation, Etymology, etc. By John 
M. Keating, M. D., LL.D., Fellow of the College of Physicians of Phila- 
delphia ; Vice-President of the American Pediatric Society ; Ex-President 
of the Association of Life Insurance Medical Directors ; Editor " Cyclo- 
paedia of the Diseases of Children," etc. ; and Henry Hamilton, author 
of "A New Translation of Virgil's ^Eneid into English Rhyme;" co- 
author of " Saunders' Medical Lexicon," etc. ; with the Collaboration of 
J. Chalmers DaCosta, M. D., and Frederick A. Packard, M. D. 
With an Appendix containing important Tables of Bacilli, Micrococci, 
Leucomaines, Ptomaines, Drugs and Materials used in Antiseptic Sur- 
gery, Poisons and their Antidotes, Weights and Measures, Thermometric 
Scales, New Official and Unofficial Drugs, etc. One very attractive volume 
of over 800 pages. Second Revised Edition. Prices : Cloth, $5.00 net ; 
Sheep or Half-Morocco, $6.00 net ; with Denison's Patent Ready-Refer- 
ence Index; without patent index, Cloth, $4.00 net; Sheep or Half- 
Morocco, $5.00 net. 

PROFESSIONAL OPINIONS. 

" I am much pleased with Keating's Dictionary, and shall take pleasure in recommending 
it to my classes." 

Henry M. Lyman, M. D., 
Professor of Principles and Practice of Medicine, Rush Medical College, Chicago, III. 

" I am convinced that it will be a very valuable adjunct to my study-table, convenient in 
size and sufficiently full for ordinary use." 

C. A. Lindsley, M. D., 
Professor of Theory and Practice of Medicine, Medical De fit. Yale University : 

Secretary Connecticut State Board of Health, New Haven, Conn, 



AUTOBIOGRAPHY OF SAMUEL D. GROSS, M. D., Emeritus Pro- 
fessor of Surgery in the Jefferson Medical College of Philadelphia, with 
Reminiscences of His Times and Contemporaries. Edited by his sons, 
Samuel W. Gross, M. D., LL.D., late Professor of Principles of Surgery 
and of Clinical Surgery in the Jefferson Medical College, and A. Haller 
Gross, A. M., of the Philadelphia Bar. Preceded by a Memoir of Dr. 
Gross, by the late Austin Flint, M. D., LL.D. In two handsome volumes, 
each containing over 400 pages, demy 8vo, extra cloth, gilt tops, with fine 
Frontispiece engraved on steel. Price per Volume, $2.50 net. 
1 his autobiography, which was continued by the late eminent surgeon until 
within three months of his death, contains a full and accurate history of his 
early struggles, trials, and subsequent successes, told in a singularly interesting 
and charming manner, and embraces short and graphic pen-portraits of many 
of the most distinguished men — surgeons, physicians, divines, lawyers, states- 
men, scientists, etc. — with whom he was brought in contact in America and in 
Europe ; the whole forming a retrospect of more than three-quarters of a century. 



CATALOGUE OF MEDICAL WORKS. 2 J 

PRACTICAL POINTS IN NURSING. For Nurses in Private 
Practice. By Emily A. M. Stoney, Graduate of the Training-School 
tor Nurses, Lawrence, Mass. ; Superintendent of the Training-School for 
Nurses, Carney Hospital, South Boston, Mass. 456 pages, handsomely 
illustrated with 73 engravings in the textj and 9 colored and half-tone 
Dlates. Cloth. Price, $1.75 nex, 

SECOND EDITION, THOROUGHLY REVISED. 

In this volume the author explains, in popular language and in the shortest 
possible form, the entire range of private, nursing as distinguished from hospital 
nursing, and the nurse is instructed how best to meet the various emergencies of 
medical and surgical cases when distant from medical or surgical aid or when 
thrown on her own resources. 

An especially valuable feature of the work will be found in the directions to 
the nurse how to improvise everything ordinarily needed in the sick-room, where 
the embarrassment of the nurse, owing to the want of proper appliances, is fre- 
quently extreme. 

The work has been logically divided into the following sections : 

I. The Nurse : her responsibilities, qualihcations, equipment, etc. 
II. The Sick-Room : its selection, preparation, and management. 
T JI. The Patient : duties of the nurse in medical, surgical, obstetric, and gyne- 
cologic cases. 
IV. Nursing in Accidents and Emergencies. 
V. Nursing in Special Medical Cases. 
VI. Nursing of the New-born and Sick Children. 
VII. Physiology and Descriptive Anatomy. 

The Appendix contains much information in compact form that will be found 
of great value to the nurse, including Rules for Feeding the Sick; Recipes for 
Invalid Foods and Beverages ; Tables of Weights and Measures ; Table for 
Computing the Date of Labor ; List of Abbreviations : Dose-List ; and a full 
and complete Glossary of Medical Terms and Nursing Treatment. 

" This is a well-written, eminently practical volume, which covers the entire range of 
private nursing as distinguished from hospital nursing, and instructs the nurse how best to 
meet the various emergencies which may arise and how to prepare everything ordinarily 
needed in the illness of her patient." — American Journal of Obstetrics and Diseases of 
Women and Children, Aug., 1896. 

A TEXT-BOOK OF BACTERIOLOGY, including the Etiology and 
Prevention of Infective Diseases and an account of Yeasts and Moulds, 
Haematozoa, and Psorosperms. By Edgar M. Crookshank, M. B., Pro- 
fessor of Comparative Pathology and Bacteriology, King's College, London. 
A handsome octavo volume of 700 pages, with 273 engravings in the text, 
ana 22 original and colored plates. Price, $6.50 net. 

This book, though nominally a Fourth Edition of Professor Crookshank's 
" Manual of Bacteriology," is practically a new work, the old one having 
been reconstructed, greatly enlarged, revised throughout, and largely rewritten, 
forming a text-book for the Bacteriological Laboratory, for Medical Ofiicers of 
Health, and for Veterinary Inspectors. 



28 W. B. SAUNDERS' 



MEDICAL DIAGNOSIS. By Dr. Oswald Vierordt, Professor of 
Medicine at the University of Heidelberg. Translated, with additions, 
from the Fifth Enlarged German Edition, with the author's permission, by 
Francis H. Stuart, A. M., M. D. In one handsome royal-octavo volume 
of 600 pages. 194 fine wood-cuts in the text, many of them in colors. 
Prices: Cloth, $4.00 net; Sheep or Half- Morocco, $5.00 net. 

FOURTH AMERICAN EDITION, FROM THE FIFTH REVISED AND 
ENLARGED GERMAN EDITION. 

In this work, as in no other hitherto published, are given full and accurate 
explanations of the phenomena observed at the bedside. It is distinctly a clin- 
ical work by a master teacher, characterized by thoroughness, fulness, and accu- 
racy. It is a mine of information upon the points that are so often passed over 
without explanation. Especial attention has been given to the germ-theory as a 
factor in the origin of disease. 

The present edition of this highly successful work has been translated from 
the fifth German edition. Many alterations have been made throughout the 
book, but especially in the sections on Gastric Digestion and the Nervous System. 

It will be found that all the qualities which served to make the earlier editions 
so acceptable have been developed with the evolution of the work to its present 
form. 

THE PICTORIAL ATLAS OF SKIN DISEASES AND SYPHI- 
LITIC AFFECTIONS. (American Edition.) Translation from 
the French. Edited by J. J. Pringle, M. B., F. R. C. P., Assistant Phy- 
sician to, and Physician to the department for Diseases of the Skin at, the 
Middlesex Hospital, London. Photo-lithochromes from the famous models 
of dermatological and syphilitic cases in the Museum of the Saint-Louis 
Hospital, Paris, with explanatory wood-cuts and letter-press. In 12 Parts, 
at $3.00 per Part. 

" Of all the atlases of skin diseases which have been published in recent years, the present 
one promises to be of greatest interest and value, especially from the standpoint of the 
general practitioner." — American Medico -Surgical Bulletin, Feb. 22, 1896. 

"The introduction of explanatory wood-cuts in the text is a novel and most important 
feature which greatly furthers the easier understanding of the excellent plates, than which 
nothing, we venture to say, has been seen better in point of correctness, beauty, and general 
merit." — New York Medical Journal , Feb. 15, 1896. 

" An interesting feature of the Atlas is the descriptive text, which is written for each picture 
by the physician who treated the case or at whose instigation the models have been made. 
We predict for this truly beautiful work a large circulation in all parts of the medical world 
where the names St. Louis and Baretta have preceded it." — Medical Record, N. Y., Feb. 1, 
1896. 

A TEXT-BOOK OF MECHANO-THERAPY (MASSAGE AND 
MEDICAL GYMNASTICS). By Axel V. Grafstrom, B. Sc, 
M. D., late Lieutenant in the Royal Swedish Army; late House Physi- 
cian, City Hospital, Blackwell's Island, New York. i2mo, 139 pages, 
illustrated. Cloth, $1.00 net. 



CATALOGUE OF MEDICAL WORKS. 29 

DISEASES OF THE EYE. A Hand-Book of Ophthalmic Prac- 
tice. By G. E. de Schweinitz, M. D., Professor of Ophthalmology in 
the Jefferson Medical College, Philadelphia, etc. A handsome royal- 
octavo volume of 696 pages, with 255 fine illustrations, many of which are 
original, and 2 chromo-lithographic plates. Prices : Cloth, $4.00 net ; 
Sheep or Half-Morocco, $5.00 net. 

THIRD EDITION, THOROUGHLY REVISED. 

In the third edition of this text-book, destined, it is hoped, to meet the favor- 
able reception which has been accorded to its predecessors, the work has been 
revised thoroughly, and much new matter has been introduced. Particular 
attention has been given to the important relations which micro-organisms bear 
to many ocular diseases. A number of special paragraphs on new subjects have 
been introduced, and certain articles, including a portion of the chapter on 
Operations, have been largely rewritten, or at least materially changed. A 
number of new illustrations have been added. The Appendix contains a full 
description of the method of determining the corneal astigmatism with the 
ophthalmometer of Javal and Schiotz, and the rotation of the eyes with the 
tropometer of Stevens. 

" A work that will meet the requirements not only of the specialist, but of the general 
practitioner in a rare degree. I am satisfied that unusual success awaits it." 

William Pepper, M. D. 
Provost and Professor of Theory and Practice of Medicine and Clinical Medicine 
in the University of Pennsylvania. 

"A clearly written, comprehensive manual. . . . One which we can commend to students 
as a reliable text-book, written with an evident knowledge of the wants of those entering upon 
the study of this special branch of medical science." — British Medical 'Journal. 

" It is hardly too much to say that for the student and practitioner beginning the study of 
Ophthalmology, it is the best single volume at present published." — Medical News. 

" It is a very useful, satisfactory, and safe guide for the student and the practitioner, artd 
one of the best works of this scope in the English language." — Annals of Ophthalmology. 

DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant 
Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital, London ; 
and Arthur E. Giles, M. D., B. Sc, Lond., F. R.C. S., Edin., Assistant 
Surgeon to Chelsea Hospital, London. 436 pages, handsomely illustrated. 
Cloth, $2.50 net. 

The authors have placed in the hands of the physician and student a concise 
yet comprehensive guide to the study of gynecology in its most modern develop- 
ment. It has been their aim to relate facts and describe methods belonging to 
the science and art of gynecology in a way that will prove useful to students for 
examination purposes, and which will also enable the general physician to prac- 
tice this important department of surgery with advantage to his patients and with 
satisfaction to himself. 

" The book is very well prepared, and is certain to be well received by the medical public." 
— British Medical Journal. 

"The text has been carefully prepared. Nothing essential has been omitted, and its 
teachings are those recommended by the leading authorities of the day."— Journal of the 
American Medical Association. 



30 m £. SAIWDEKT 



TEXT-BOOK UPON THE PATHOGENIC BACTERIA. Spe- 
cially written for Students of Medicine. By Joseph McFarland, 
M. D., Professor of Pathology and Bacteriology in the Medico-Chirurgicai 
College of Philadelphia, etc. 497 pages, finely illustrated. Price, Cloth, 
$2.50 net, 

SECOND EDITION, REVISED AND GREATLY ENLARGED. 
The work is intended to be a text-book for the medical student and for the 
practitioner who has had no recent laboratory training in this department of medi- 
cal science. The instructions given as to needed apparatus, cultures, stainings, 
microscopic examinations, etc. are ample for the student's needs, and will afford 
to the physician much information that will "interest and profit him relative to a 
subject which modern science shows to go far in explaining the etiology of many 
diseased conditions. 

In this second edition the work has been brought up to date in all depart- 
ments of the subject, and numerous additions have been made to the technique 
in the endeavor to make the book fulfil the double purpose of a systematic work 
upon bacteria and a laboratory guide. 

" It is excellently adapted for the medical students and practitioners for whom it is avowedly 
written. . . . The descriptions given are accurate and readable, and the book should prove 
useful to those for whom it is written. — London Lancet, Aug. 29, 1896. 

" The author has succeded admirably in presenting the essential details of bacteriological 
technics, together with a judiciously chosen summary of our present knowledge of pathogenic 
bacteria. . . . The work, we think, should have a wide circulation among English-speaking 
students of medicine." — N. Y. Medical Journal, April 4, 1896. 

" The book will be found of considerable use by medical men who have not had a special 
bacteriological training, and who desire to understand this important branch of medical 
science." — Edinburgh Medical Journal, July, 1896. 

LABORATORY GUIDE FOR THE BACTERIOLOGIST. By 

Langdon Frothingham, M. D. V., Assistant in Bacteriology and Veteri- 
nary Science, Sheffield Scientific School. Yale University. Illustrated. 
Price, Cloth, 75 cents. 

The technical methods involved in bacteria-culture, methods of staining, ana 
microscopical study are fully described and arranged as simply and concisely as 
possible. The book is especially intended for use in laboratory work, 

" It is a convenient and useful little work, and will more than repay the outlay necessary 
for its purchase in the saving of time which would otherwise be consumed in looking up the 
various points of technique so clearly and concisely laid down in its pages." — American Med.- 
Surg. Bulletin, 

FEEDING IN EARLY INFANCY. By Arthur V. Meigs. M. D. 
Bound in limp cloth, flush edges. Price, 25 cents net. 

Synopsis : Analyses of Milk — Importance of the Subject of Feeding in Early 
Infancy — Proportion of Casein and Sugar in Human Milk — Time to Begin Arti- 
ficial Feeding of Infants — Amount of Food to be Administered at Each Feed- 
ing — Intervals between Feedings — Increase in Amount of Food at Different 
Periods of Infant Development — Unsuitableness of Condensed Milk as a Sub- 
stitute for Mother's Milk — Objections to Sterilization or " Pasteurization " oit 
Milk — Advances made in the Method of Artificial Feeding of Infants. 



CATALOGUE OF MEDICAL WORKS. 



MATERIA MEDICA FOR NURSES. By Emily A. M. Stoney, 

Graduate of the Training-school for Nurses, Lawrence, Mass. ; late 
Superintendent of the Training-school for Nurses, Carney Hospital, South 
Boston, Mass. Handsome octavo, 300 pages. Cloth, $1.50 net. 

The present book differs from other similar works in several features, all of 
which are introduced to render it more practical and generally useful. The 
general plan of contents follows the lines laid down in training-schools for 
nurses, but the book contains much useful matter not usually included in works 
of this character, such as Poison-emergencies, Ready Dose-list, Weights and 
Measures, etc., as well as a Glossary, defining all the terms in Materia Medica, 
and describing all the latest drugs and remedies, which have been generally 
neglected by other books of the kind. 

ESSENTIALS OF ANATOMY AND MANUAL OF PRACTI- 
CAL DISSECTION, containing " Hints on Dissection." By Charles 
B. Nancrede, M. D., Professor of Surgery and Clinical Surgery in the 
University of Michigan, Ann Arbor; Corresponding Member of the Royal 
Academy of. Medicine, Rome, Italy ; late Surgeon Jefferson Medical Col- 
lege, etc. Fourth and revised edition. Fost 8vo, over 500 pages, with 
handsome full-page lithographic plates in colors, and over 200 illustrations. 
Price : Extra Cloth or Oilcloth for the dissection-room, $2.00 net. 

Neither pains nor expense has been spared to make this work the most ex- 
haustive yet concise Student's Manual of Anatomy and Dissection ever pub' 
lished, either in America or in Europe. 

The colored plates are designed to aid the student in dissecting the muscles^ 
arteries, veins, and nerves. The wood-cuts have all been specially drawn ancj 
engraved, and an Appendix added containing 60 illustrations representing the 
structure of the entire human skeleton, the wdiole being based on the eleventh 
edition of Gray's Anatomy. 

A MANUAL OF PRACTICE OF MEDICINE. By A. A. Stevens, 
A. M., M. D., Instructor in Physical Diagnosis in the University of Penn- 
sylvania, and Professor of Pathology in the Woman's Medical College of 
Pennsylvania. Specially intended for students preparing for graduation 
and hospital examinations. Post 8vo, 519 pages. Numerous illustrations 
and selected formulae. Price, bound in flexible leather, $2.00 net. 

FIFTH EDITION, REVISED AND ENLARGED. 

Contributions to the science of medicine have poured in so rapidly during the 
last quarter of a century that it is well-nigh impossible for the student, with the 
limited time at his disposal, to master elaborate treatises or to cull from them 
that knowledge which is absolutely essential. From an extended experience in 
teaching, the author has been enabled, by classification, to group allied symp- 
toms, and by the judicious elimination of theories and redundant explanations 
to bring within a comparatively small compass a complete outline of the prac- 
tice of medicine. 



32 W. B. SAUNDERS' 



MANUAL OF MATERIA MEDICA AND THERAPEUTICS. 

By A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the 
University of Pennsylvania, and Professor of Pathology in the Woman's 
Medical College of Pennsylvania. 445 pages. Price, bound in flexible 
leather, $2.25. 

SECOND EDITION, REVISED. 

This wholly new volume, which is based on the last edition of the Pharma- 
copoeia, comprehends the following sections : Physiological Action of Drugs ; 
Drugs; Remedial Measures other than Drugs; Applied Therapeutics; Incom- 
patibility in Prescriptions; Table of Doses; Index of Drugs; and Index of 
Diseases; the treatment being elucidated by more than two hundred formulae. 

"The author is to be congratulated upon having presented the medical student with as 
accurate a manual of therapeutics as it is possible to prepare."— Therapeutic Gazette. 

" Far superior to most of its class ; in fact, it is very good. Moreover, the book is reliable 
and accurate." — New York Medical Journal. 

" The author has faithfully presented modern therapeutics in a comprehensive work, . . . 
and it will be found a reliable guide." — University Medical Magazine. 

NOTES ON THE NEWER REMEDIES: their Therapeutic Ap- 
plications and Modes of Administration. By David Cerna, M. D., 
Ph. D., Demonstrator of and Lecturer on Experimental Therapeutics in 
the University of Pennsylvania. Post-octavo, 253 pages. Price, #1.25. 

SECOND EDITION, RE-WRITTEN AND GREATLY ENLARGED. 

The work takes up in alphabetical order all the newer remedies, giving their 
physical properties, solubility, therapeutic applications, administration, and 
chemical formula. 

It thus forms a very valuable addition to the various works on therapeutics 
now in existence. 

Chemists are so multiplying compounds, that, if each compound is to be thor- 
oughly studied, investigations must be carried far enough to determine the prac- 
tical importance of the new agents. 

" Especially valuable because of its completeness, its accuracy, its systematic consider- 
ation of the properties and therapy of many remedies of which doctors generally know but 
little, expressed in a brief yet terse manner." — Chicago Clinical Review. 



TEMPERATURE CHART. Prepared by D. T. Laine, M. D. Size 
8x 13% inches. Price, per pad of 25 charts, 50 cents. 

A conveniently arranged chart for recording Temperature, with columns for 
daily amounts of Urinary and Fecal Excretions, Food, Remarks, etc. On the 
back of each chart is given in full the method of Brand in the treatment of 
Typhoid Fever. 



CATALOGUE OF MEDICAL WORKS. 33 

A TEXT-BOOK OF HISTOLOGY, DESCRIPTIVE AND PRAC- 
TICAL. For the Use of Students. By Arthur Clarkson, M. B., 
C. M., Edin., formerly Demonstrator of Physiology in the Owen's College, 
Manchester; late Demonstrator of Physiology in the Yorkshire College, 
Leeds. Large 8vo, 554 pages, with 22 engravings in the text, and 174 
beautifully colored original illustrations. Price, strongly bound in Cloth, 
$4.00 net. 

The purpose of the writer in this work has been to furnish the student of His- 
tology, in one volume, with both the descriptive and the practical part of the 
science. The first two chapters are devoted to the consideration of the general 
methods of Histology ; subsequently, in each chapter, the structure of the tissue 
or organ is first systematically described, the student is then taken tutorially over 
the specimens illustrating it, and, finally, an appendix affords a short note of the 
methods of preparation. 

" The work must be considered a valuable addition to the list of available text-books, and 
is to be highly recommended." — New York Medical Journal. 

" One of the best works for students we have ever noticed. We predict that the book will 
attain a well-deserved popularity among our students." — Chicago Medical Recorder. 

THE PATHOLOGY AND TREATMENT OF SEXUAL IM- 
POTENCE. By Victor G. Vecki, M. D. From the second Ger- 
man edition, revised and rewritten. Demi-octavo, about 300 pages. 
Cloth, $2.00 net. 

The subject of impotence has but seldom been treated in this country in the 
truly scientific spirit that it deserves, and this volume will come to many as a 
revelation of the possibilities of therapeusis in this important field. Dr. Vecki's 
work has long been favorably known, and the German book has received the 
highest consideration. This edition is more than a mere translation, for, although 
based on the German edition, it has been entirely rewritten by the author in 
English. 

" The work can be recommended as a scholarly treatise on its subject, and it can be read 
with advantage by many practitioners."— -Journal of the American Medical Association. 

THE TREATMENT OF PELVIC INFLAMMATIONS 
THROUGH THE VAGINA. By W. R. Pryor, M.D., Pro- 
fessor of Gynecology in the New York Polyclinic. i2mo, 248 pages, 
handsomely illustrated. Cloth, $2.00 net. 

In this book the author directs the attention of the general practitioner to a 
surgical treatment of the pelvic diseases of women. There exists the utmost 
confusion in the profession regarding the most successful methods of treating 
pelvic inflammations ; and inasmuch as inflammatory lesions constitute the ma- 
jority of all pelvic diseases, the subject is an important one. It has been the 
endeavor of the author to put down every little detail, no matter how insig- 
nificant, which might be of service. 



34 W. B. SAUNDERS' 



DISEASES OF WOMEN. By Henry J. Garrigues, A.M., M. D., 
Professor of Gynecology in the New York School of Clinical Medicine; 
Gynecologist to St. Mark's Hospital and to the German Dispensary, New 
York City. In one handsome octavo volume of 728 pages, illustrated by 
335 engravings and colored plates. Prices: Cloth, $4.00 net; Sheep or 
Half-Morocco, #5.00 net. 

A practical work on gynecology for the use of students and practitioners, 
written in a terse and concise manner. The importance of a thorough know- 
ledge of the anatomy of the female pelvic organs has been fully recognized by 
the author, and considerable space has been devoted to the subject. The chap- 
ters on Operations and on Treatment are thoroughly modern, and are based 
upon the large hospital and private practice of the author. The text is eluci- 
dated by a large number of illustrations and colored plates, many of them being 
original, and forming a complete atlas for studying embryology and the anatomy 
of the female genitalia, besides exemplifying, whenever needed, morbid condi- 
tions, instruments, apparatus, and operations. 

Second Edition, Thoroughly Revised, 

The first edition of this work met with a most appreciative reception by the 
medical press and profession both in this country and abroad, and was adopted 
as a text-book or recommended as a book of reference by nearly one hundred 
colleges in the United States and Canada. The author has availed himself of 
the opportunity afforded by this revision to embody the latest approved advances 
in the treatment employed in this important branch of Medicine. He has also 
more extensively expressed his own opinion on the comparative value of the 
different methods of treatment employed. 

"One of the best text-books for students and practitioners which has been published in 
the English language; it is condensed, clear, and comprehensive. The profound learning 
and great clinical experience of the distinguished author find expression in this book in a 
most attractive and instructive form. Young practitioners, to whom experienced consultants 
may not be available, will find in this book invaluable counsel and help." 

Thad. A. Reamy, M. D., LL.D., 
Professor of Clinical Gynecology , Medical College of Ohio ; Gynecologist to the Good 
Samaritan and Cincinnati Hospitals. 



A SYLLABUS OF GYNECOLOGY, arranged in conformity with 
"An American Text-Book of Gynecology." By J. W. Long, M. D., 
Professor of Diseases of Women and Children, Medical College of Vir- 
ginia, etc. Price, Cloth (interleaved), $1.00 net. 

Based upon the teaching and methods laid down in the larger work, this will 
not only be useful as a supplementary volume, but to those who do not already 
possess the text-book it will also have an independent value as an aid to the 
practitioner in gynecological work, and to the student as a guide in the lecture- 
room, as the subject is presented in a manner at once systematic, clear, succinct, 
?nd practical. 



CATALOGUE OF MEDICAL WORKS. 35 

THE AMERICAN POCKET MEDICAL DICTIONARY. Edited 
by W. A. Newman Dor land, M. D., Assistant Obstetrician to the Hospital 
of the University of Pennsylvania ; Fellow of the ' American Academy of 
Medicine. Containing the pronunciation and definition of all the principal 
words used in medicine and the kindred sciences, with 64 extensive tables. 
Handsomely bound in flexible leather, limp, with gold edges and patent 
thumb index. Price, $1.00 net ; with thumb index, #1.25 net. 

SECOND EDITION, REVISED. 

This is the ideal pocket lexicon. It is an absolutely new book, and not a re- 
vision of any old work. It is complete, defining all the terms of modern medi- 
cine and forming an unusually complete vocabulary. It gives the pronunciation 
of all the terms. It makes a special feature of the newer words neglected by 
other dictionaries. It contains a wealth of anatomical tables of special value to 
students. It forms a handy volume, indispensable to every medical man. 

SAUNDERS' POCKET MEDICAL FORMULARY. By William 

M. Powell, M. D., Attending Physician to the Mercer House for Invalid 
Women at Atlantic City. Containing 1800 Formulae, selected from several 
hundred of the best-known authorities. Forming a handsome and con- 
venient pocket companion of nearly 300 printed pages, with blank leaves 
for Additions; with an Appendix containing Posological Table, Formulae 
and Doses for Hypodermatic Medication, Poisons and their Antidotes, 
Diameters of the Pemale Pelvis and Fcetal Head, Obstetrical Table, Diet 
List for Various Diseases, Materials and Drugs used in Antiseptic Surgery, 
Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables 
of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- 
somely bound in morocco, with side index, wallet, and flap. Price, $1.75 
net. 

FIFTH EDITION, THOROUGHLY REVISED. 

"This little book, that can be conveniently carried in the pocket, contains an immense 
amount of material. It is very useful, and as the name of the author of each prescription is 
given,is unusually reliable." — New York Medical Record. 

A COMPENDIUM OF INSANITY. By John B. Chapin, M.D., LL.D., 
Physician-in- Chief, Pennsylvania Hospital for the Insane; late Physician- 
Superintendent oPthe Willard State Hospital, New York ; Honorary Mem- 
ber of the Medico- Psychological Society of Great Britain, of the Society of 
Mental Medicine of Belgium. i2mo, 234 pages, Must. Cloth, #1.25 net. 

The author has given, in a condensed and concise form, a compendium of 
Diseases of the Mind, for the convenient use and aid of physicians and students. 
It contains a clear, concise statement of the clinical aspects of the various ab- 
normal mental conditions, with directions as to the most approved methods of 
managing and treating the insane. 

" The practical parts of Dr. Chapin's book are what constitute its distinctive merit. We 
desire especially, however, to call attention to the fact that in the subject of the therapeutics 
of insanity the work is exceedingly valuable. The author has made a distinct addition to the 
literature of his specialty." — Philadelphia Medical Journal. 



2>6 W. B. SAUNDERS' 



AN OPERATION BLANK, with Lists of Instruments, etc. re- 
quired in Various Operations. Prepared by W. W. Keen, M. D., 
LL.D., Professor of Principles of Surgery in the Jefferson Medical Col- 
lege, Philadelphia. Price per Pad, containing Blanks for fifty operations, 
50 cents net. 

SECOND EDITION, REVISED FORM. 

A convenient blank, suitable for all operations, giving complete instructions 
regarding necessary preparation of patient, etc., with a full list of dressings and 
medicines to be employed. 

On the back of each blank is a list of instruments used — viz. general instru 
ments, etc., required for all operations ; and special instruments for surgery of 
the brain and spine, mouth and throat, abdomen, rectum, male and female 
genito-urinary organs, the bones, etc. 

The whole forming a neat pad, arranged for hanging on the wall of a sur- 
geon's office or in the hospital operating-room. 

" Will serve a useful purpose for the surgeon in reminding him of the details of prepa- 
ration for the patient and the room as well as for the instruments, dressings, and antiseptics 
needed." — New York Medical Record 

" Covers about all that can be needed in any operation." — American Lancet. 

" The plan is a capital one." — Boston Medical and Surgical journal. 

LABORATORY EXERCISES IN BOTANY. By Edson S. Bastin, 
M. A., Professor of Materia Medica and Botany in the Philadelphia Col- 
lege of Pharmacy. Octavo volume of 536 pages, 8j full-page plates. Price, 
Cloth, $2.50. 

This work is intended for the beginner and the advanced student, and it fully 
covers the structure of flowering plants, roots, ordinary stems, rhizomes, tubers, 
bulbs, leaves, flowers, fruits, and seeds. Particular attention is given to the gross 
and microscopical structure of plants, and to those used in medicine. Illustra- 
tions have freely been used to elucidate the text, and a complete index to facil- 
itate reference has been added. 

" There is no work like it in the pharmaceutical or botanical literature of this country, and 
we predict for it a wide circulation." — American Journal of Pharmacy. 

DIET IN SICKNESS AND IN HEALTH. By Mrs. Ernest Hart, 
formerly Student of the Faculty of Medicine of Paris and of the London 
School of Medicine for Women; with an Introduction by Sir Henry 
Thompson, F. R. C. S., M. D., London. 220 pages; illustrated. Price, 
Cloth, 1 1. 50. 

Useful to those who have to nurse, feed, and prescribe for the sick. In 
each case the accepted causation of the disease and the reasons for the special 
diet prescribed are briefly described. Medical men will find the dietaries and 
recipes practically useful, and likely to save them trouble in directing the dietetic 
treatment of patients. 



CATALOGUE OF MEDICAL WORKS. 37 

A. MANUAL OF PHYSIOLOGY, with Practical Exercises. For 

Students and Practitioners. By G. N. Stewart, M. A., M. D., D. Sc., 

lately Examiner in Physiology, University of Aberdeen, and of the New 

Museums, Cambridge University ; Professor of Physiology in the Western 

Reserve University, Cleveland, Ohio. Handsome octavo volume of 848 

pages, with 300 illustrations in the text, and 5 colored plates. Price, Cloth, 

#3.75 net. 

THIRD EDITION, REVISED. 

" It will make its way by sheer force of merit, and amply deserves to do so. It is one of 
the very best English text-books on the subject." — London Lancet. 

" Of the many text-books of physiology published, we do not know of one that so nearly 
comes up to the ideal as does Professor Stewart's volume." — British Medical Journal. 

ESSENTIALS OF PHYSICAL DIAGNOSIS OF THE THORAX. 

By Arthur M. Corwin, A. M., M. D., Demonstrator of Physical Diagno- 
sis in the Rush Medical College, Chicago; Attending Physician to the 
Central Free Dispensary, Department of Rhinology, Laryngology, and 
Diseases of the Chest. 219 pages. Illustrated. Cloth, flexible covers. 
Price, $1.25 net. 

THIRD EDITION, THOROUGHLY REVISED AND ENLARGED. 
SYLLABUS OF OBSTETRICAL LECTURES in the Medical 
Department, University of Pennsylvania. By Richard C. Norris, 
A. M., M. D., Lecturer on Clinical and Operative Obstetrics, University 
of Pennsylvania. Third edition, thoroughly revised and enlarged. Crown 
8vo. Price, Cloth, interleaved for notes, $2.00 net. 

" This work is so far superior to others on the same subject that we take pleasure in call- 
ing attention briefly to its excellent features. It covers the subject thoroughly, and will 
prove invaluable both to the student and the practitioner. The author has introduced a 
number of valuable hints which would only occur to one who was himself an experienced 
teacher of obstetrics. The subject-matter is clear, forcible, and modern. We are especially 
pleased with the portion devoted to the practical duties of the accoucheur, care of the child, 
etc. The paragraphs on antiseptics are admirable; there is no doubtful tone in the direc- 
tions given. No details are regarded as unimportant ; no minor matters omitted. We ven- 
ture to say that even the old practitioner will find useful hints in this direction which he can- 
not afford to despise." — New York Medical Record. 

A SYLLABUS OF LECTURES ON THE PRACTICE OF SUR- 
GERY, arranged in conformity with " An American Text-Book 
of Surgery." By N. Senn, M. D., Ph. D., Professor of Surgery in Rush 
Medical College, Chicago, and in the Chicago Polyclinic. Price, $2.00. 

This work by so eminent an author, himself one of the contributors to 
" An American Text-Book of Surgery," will prove of exceptional value to 
the advanced student who has adopted that work as his text-book. It is not 
only the syllabus of an unrivalled course of surgical practice, but it is also an 
epitome of or supplement to the larger work. 

" The author has evidently spared no pains in making his Syllabus thoroughly comprehen- 
sive, and has added new matter and alluded to the most recent authors and operations. Full 
references are also given to all requisite details of surgical anatomy and pathology." — British 
Medical Journal, London. 



3 8 W. B. SAUNDERS' 



THE CARE OF THE BABY. By J. P. Crozer Griffith, M. I)., 
Clinical Professor of Diseases of Children, University of Pennsylvania; 
Physician to the Children's Hospital', Philadelphia, etc. 404 pages, with 
67 illustrations in the text, and 5 plates. i2mo. Price, #1.50. 

SECOND EDITION, REVISED. 

A reliable guide not only for mothers, but also for medical students and 
practitioners whose opportunities for observing children have been limited. 

"The whole book is characterized by rare good sense, and is evidently written by a mas. 
ter hand. _ It can be read with benefit not only by mothers, but by medical students and by 
any practitioners who have not had large opportunities for observing children."— American 
Journal of Obstetrics. 

THE NURSE'S DICTIONARY of Medical Terms and Nursing 
Treatment, containing Definitions of the Principal Medical and Nursing 
Terms, Abbreviations, and Physiological Names, and Descriptions of the 
Instruments, Drugs, Diseases, Accidents, Treatments, Operations, Foods, 
Appliances, etc. encountered in the ward or the sick-room. By Honnor 
Morten, author of " How to Become a Nurse," " Sketches of Hospital 
Life," etc. i6mo, 140 pages. Price, Cloth, $1.00. 

This little volume is intended for use merely as a small reference-book which 
can be consulted at the bedside or in the ward. It gives sufficient explanation 
to the nurse to enable her to comprehend a case until she has leisure to look up 
larger and fuller works on the subject. 

DIET LISTS AND SICK-ROOM DIETARY. By Jerome B. Thomas, 
M. D., Visiting Physicia-n to the Home for Friendless Women and Children 
and to the Newsboys' Home ; Assistant Visiting Physician to the Kings 
County Hospital; Assistant Bacteriologist, Brooklyn Health Department. 
Price, Cloth, $1.50 (Send for specimen List.) 

One hundred and sixty detachable (perforated) diet lists for Albuminuria, 
Anaemia and Debility, Constipation, Diabetes, Diarrhoea, Dyspepsia, Fevers, 
Gout or Uric- Acid Diathesis, Obesity, and Tuberculosis. Also forty detachable 
sheets of Sick-Room Dietary, containing full instructions for preparation of 
easily-digested foods necessary for invalids. Each list is numbered only, the 
disease for which it is to be used in no case being mentioned, an index key 
being reserved for the physician's private use. 

DIETS FOR INFANTS AND CHILDREN IN HEALTH AND 
IN DISEASE. By Louis Starr, M. D., Editor of "An American 
Text-Book of the Diseases of Children." 230 blanks (pocket-book size), 
perforated and neatly bound in flexible morocco. Price, $1.25 net. 

The first series of blanks are prepared for the first seven months of infant 
life ; each blank indicates the ingredients, but not the quantities, of the food, 
the latter directions being left for the physician. After the seventh month, 
modifications being less necessary, the diet lists are printed in full. Formula 
foi tne preparation of diluents and foods are appended. 



CATALOGUE OF MEDICAL WORKS. 39 

HOW TO EXAMINE FOR LIFE INSURANCE. By Joi*N M. 
Keating, M. D., Fellow of the College of Physicians and Surgeons of 
Philadelphia; Vice-President of the American Pediatric Society; Ex- 
President of the Association of Life Insurance Medical Directors. Royal 
8vo, 211 pages, with two large half-tone illustrations, and a plate prepared 
by Dr. McClellan from special dissections ; also, numerous cuts to elucidate 
the text. Third edition. Price, Cloth, $2.00 net. 

" This is by far the most useful book which has yet appeared on insurance examination, a 
subject of growing interest and importance. Not the least valuable portion of the volume is 
Part II., which consists of instructions issued to their examining physicians by twenty-four 
representative companies of this country. As the proofs of these instructions were corrected 
by the directors of the companies, they form the latest instructions obtainable, If for these 
alone, the book should be at the right hand of every physician interested in this special branch 
of medical science." — The Medical News, Philadelphia. 

NURSING: ITS PRINCIPLES AND PRACTICE. By Isabel 

Adams Hampton, Graduate of the New York Training School for 
Nurses attached to Bellevue Hospital; Superintendent of Nurses and 
Principal of the Training School for Nurses, Johns Hopkins Hospital, 
Baltimore, Md. ; late Superintendent of Nurses, Illinois Training School 
for Nurses, Chicago, 111. In one very handsome i2mo volume of 512 
pages, illustrated. Price, Cloth, $2.00 net. 

SECOND EDITION, REVISED AND ENLARGED. 

This original work on the important subject of nursing is at once comprehensive 
and systematic. It is written in a clear, accurate, and readable style, suitable 
alike to the student and the lay reader. Such a work has long been a desidera- 
tum with those entrusted with the management of hospitals and the instruction of 
nurses in training-schools. It is also of especial value to the graduated nurse 
who desires to acquire a practical working knowledge of the care of the sick 
and the hygiene of the sick-room. 

OBSTETRIC ACCIDENTS, EMERGENCIES, AND OPERA- 
TIONS. By L. Ch. Boisliniere, M. D., late Emeritus Professor of 
Obstetrics in the St. Louis Medical College. 381 pages, handsomely illus- 
trated. Price, $2.00 net. 

" For the use of the practitioner who, when away from home, has not the 
opportunity of consulting a library or of calling a friend in consultation. He 
then, being thrown upon his own resources, will find this book of benefit in 
guiding and assisting him in emergencies." 

INFANT'S WEIGHT CHART. Designed by J. P. Crozer Grjffith, 
M. D., Clinical Professor of Diseases of Children in the University of Peniv 
sylvania. 25 charts in each pad. Price per pad, 50 cents net. 

A convenient blank for keeping a record of the child's weight during the first 
two years of life. Printed on each chart is a curve representing the average weight 
of a healthy infant, so that any deviation from the normal can readily be detected. 




V ^K 



h- 





Saunders' 
New Series 
of Manuals 



for Students 
and 
Practitioners* 



THAT there exists a need for thoroughly reliable hand-books on the leading 
branches of Medicine and Surgery is a fact amply demonstrated by the 
favor with which the SAUNDERS NEW SERIES OF MANUALS have been 
received by medical students and practitioners and by the Medical Press. 
These manuals are not merely condensations from present literature, but 
are ably written by well-known authors and practitioners, most of them being 
teachers in representative American colleges. Each volume is concisely and 
authoritatively written and exhaustive in detail, without being encumbered 
with the introduction of "cases," which so largely expand the ordinary text- 
book. These manuals will therefore form an admirable collection of advanced 
lectures, useful alike to the medical student and the practitioner: to the latter, 
too busy to search through page after page of elaborate treatises for what he 
wants to know, they will prove of inestimable value ; to the former they will 
afford safe guides to the essential points of study. 

The. SAUNDERS NEW SERIES OF MANUALS are conceded to be 
superior to any similar books now on the market. No other manuals afford so 
much information in such a concise and available form. A liberal expenditure 
has enabled the publisher to render the mechanical portion of the work worthy 
of the high literary standard attained by these books. 

Any of these Manuals will be mailed on receipt of price (see next page 
Tor List). 



SAUNDERS' NEW SERIES OF MANUALS. 



VOLUMES PUBLISHED. 



PHYSIOLOGY. By Joseph Howard Raymond, A. M., M. D., Professor 
of Physiology and Hygiene and Lecturer on Gynecology in the Long 
Island College Hospital, etc. Price, #1.25 net. 

SURGERY, General and Operative. By John Chalmers DaCosta, 
M. D., Professor of Clinical Surgery, Jefferson Medical College, Philadel- 
phia. Second edition, revised and greatly enlarged. Octavo, 911 pages', 
386 illustrations. Cloth, $4.00 net ; Half- Morocco, $5.00 net. 

DOSE-BOOK AND MANUAL OF PRESCRIPTION- WRITING. 

By E. Q. Thornton, M. D. s Demonstrator of Therapeutics, Jefferson 
Medical College, Philadelphia. Price, $1.25 net. 

MEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D., Pro- 
fessor of Institutes of Medicine and Medical Jurisprudence in the Jeffer- 
son Medical College of Philadelphia, etc Price, $1.50 net.- 

SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's 
Hospital and to the German Poliklinik ; Instructor in Surgery, New York 
Post-Graduate Medical School, etc. Price, $1.25 net. 

MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct 
Professor of Anatomy and Demonstrator of Anatomy, Medical Department 
of the New York University, etc. Price, $2.50 net. 

SYPHILIS AND THE VENEREAL DISEASES. By James 
Nevins Hyde, M. D , Professor of Skin and Venereal Diseases, and 
Frank H. Montgomery, M. D., Lecturer on Dermatology and Genito- 
urinary Diseases in Rush Medical College, Chicago. Price, $2.50 net. 

PRACTICE OF MEDICINE. By George Roe Lockwood, M. D., 
Professor of Practice in the Woman's Medical College of the New York 
Infirmary, etc. Price, $2.50 net. 

OBSTETRICS. By W. A. Newman Dorland, M. D., Assistant Demon- 
strator of Obstetrics, University of Pennsylvania; Chief of Gynecological 
Dispensary, Pennsylvania Hospital. Price, $2.50 net. 

DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant 
Surgeon to the Middlesex Hospital, and Surgeon to the Chelsea Hospital 
for Women, London ; and Arthur E. Giles, M. D., B. Sc. Lond., F. R. C. S. 
Edin., Assistant Surgeon to the Chelsea Hospital for Women, London. 436 
pages, handsomely illustrated. Price, $2.50 net. 

IN PREPARATION. 

NERVOUS DISEASES. By Charles W. Burr, M. D., Clinical Profes- 
sor of Nervous Diseases, Medico-Chirurgical College, Philadelphia, etc. 

*#* There will be published in the same series, at short intervals, carefully prepared works 
on various subjects, by prominent specialists. 



SAUNDERS' QUESTION COMPENDS. 

Arranged in Question and Answer Form, 

THE LATEST, MOST COMPLETE, and BEST ILLUSTRATED 
SERIES OF COMPENDS EVER ISSUED. 



Now the Standard Authorities in Medical Literature 



Students and Practitioners in every City of the United 
States and Canada. 



THE REASON WHY. 

They are the advance guard of " Student's Helps " — that do help; they are 
the leaders in their special line, well and authoritatively written by able men, 
who, as teachers in the large colleges, know exactly what is wanted by a student 
preparing for his examinations. The judgment exercised in the selection of 
authors is fully demonstrated by their professional elevation. Chosen from the 
ranks of Demonstrators, Quiz-masters, and Assistants, most of them have be- 
come Professors and Lecturers in their respective colleges. 

Each book is of convenient size (5x7 inches), containing on an average 250 
pages, profusely illustrated, and elegantly printed in clear, readable type, on 
fine paper. 

The entire series, numbering twenty-four subjects, has been kept thoroughly 
revised and enlarged when necessary, many of them being in their fourth and 
fifth editions. 

TO SUM UP. 

Although there are numerous other Quizzes, Manuals, Aids, etc. in the mar- 
ket, none of them approach the " Blue Series of Question Compends;" and 
the claim is made for the following points of excellence : 

1. Professional distinction and reputation of authors. 

2. Conciseness, clearness, and soundness of treatment. 

3. Size of type and quality of paper and binding. 

*#* Any of these Compends will be mailed on receipt of price (see next 
page for List). 



SAUNDERS' QUESTION-COMPEND SERIES. 

Price, Cloth, $J.OO per copy, except when otherwise noted. 

1. ESSENTIALS OF PHYSIOLOGY. 4th edition. Illustrated. Revised and enlarged. 

By H. A. Hare, M. D. (Price, $1.00 net.) 

2. ESSENTIALS OF SURGERY. 7th edition, with a chapter on Appendicitis. 90 illus- 

trations. By Edward Martin, M. D. (Price, $1.00 net.) 

3. ESSENTIALS OF ANATOMY. 6th edition, thoroughly revised. 151 illustrations. 

By Charles B. Nancrede, M. D. (Price, $1.00 net.) 

4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. 

5th edition, revised, with an Appendix. By Lawrence Wolff, M. D. ($1.00 net.) 

5. ESSENTIALS OF OBSTETRICS. 4th edition, revised and enlarged. 75 illustra- 

tions. By W. Easterly Ashton, M.D. 

6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. 7 th thousand. 

46 illustrations. By C. E. Armand Semple, M. D. 

7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- 

SCRIPTION-WRITING. 5th edition. By Henry Morris, M. D. 

8,9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M.D. 
An Appendix on Urine Examin ation. Illustrated. By Lawrence Wolff, M. D. 
3d edition, enlarged by some 300 Essential Formulae, selected from eminent authori- 
ties, by Wm. M. Powell, M. D. (Double number, price $2.00.) 

10. ESSENTIALS OF GYN/ECOLOGY. 4th edition, revised. With 62 illustrations. 

By Edwin B. Cragin, M. D. 

11. ESSENTIALS OF DISEASES OF THE SKIN. 4th edition, revised and enlarged. 

71 letter-press cuts and 15 half-tone illustrations. By Henry W. Stelwagon, M.D. 
(Price, $1.00 net.) 

12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL 

DISEASES. 2d edition, revised and enlarged. 78 illustrations. By Edward 
Martin, M. D. 

13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 

130 illustrations. By C. E. Armand Semple, M. D. 

14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. 124 

illustrations. 2d edition, revised. By Edward Jackson, M. D., and E. Baldwin 
Gleason, M. D. 

15. ESSENTIALS OF DISEASES OF CHILDREN. 2d edition. By William M. 

Powell, M. D. 

16. ESSENTIALS OF EXAMINATION OF URINE. Colored " Vogel Scale," 

and numerous illustrations. By Lawrence Wolff, M. D. (Price, 75 cents.) 

17. ESSENTIALS OF DIAGNOSIS. 2*d edition, thoroughly revised. 60 illustrations. 

By S. Solis-Cohen, M. D., and A. A. Esiiner, M. D. (Price, $1.00 net.) 

18. ESSENTIALS OF PRACTICE OF PHARMACY. 2d edition, revised. By L. 

E. Sayre. 

20. ESSENTIALS OF BACTERIOLOGY. 3d edition. 82 illustrations. By M. V. 

Ball, M.D. 

21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. 48 illustrations. 

3d edition, revised. By John C Shaw, M.D. 

22. ESSENTIALS OF MEDICAL PHYSICS. 155 illustrations. 2d edition, revised. 

By Fred J. Brockway, M. D. (Price, $1.00 net.) 

23. ESSENTIALS OF MEDICAL ELECTRICITY. 65 illustrations. By David D. 

Stewart, M. D., and Edward S. Lawrance, M. D. 

24. ESSENTIALS OF DISEASES OF THE EAR. 114 illustrations. 2d edition, re- 

vised and enlarged. By E. Baldwin Gleason, M. D. 

43 



Some of the Books in Preparation for 
Publication during 1900. 



AMERICAN Text=Book of Pa= 
thology. 

Edited by Ludvig Hektoen, M.D., Pro- 
fessor of Pathology, Rush Medical College, 
Chicago; and David Riesman, M.D., De- 
monstrator of Pathological Histology, Uni- 
versity of Pennsylvania. 

AMERICAN Text=Book of Legal 
Medicine and Toxicology. 

Edited by Frederick Peterson, M.D., 
Chief of Clinic, Nervous Department, College 
of Physicians and Surgeons, New York City; 
and Walter S. Haines, M.D., Professor of 
Chemistry, Pharmacy, and Toxicology, Rush 
Medical College, Chicago. 

BECK— Fractures. 

By Carl Beck, M.D., Professor of Surgery 
in the N. Y. School of Clinical Medicine. 

BOHM, DAVIDOFF, and HU= 
BER— A Text=Book of Human 
Histology. 

Including Microscopic Technic. By 
Dr. A. A. Bohm and Dr. M. von Davidoff, 
of the Anatomical Institute of Munich, and 
G. C. Huber, M.D., Junior Professor of Anat- 
omy and Histology, University of Michigan, 
Ann Arbor. 

EICHHORST— A Text=Book of 
the Practice of Medicine. 

By Dr. Herman Eichhorst, Professor of 
Special Pathology and Therapeutics and Di- 
rector of the Medical Clinic, University of 
Zurich. Translated and edited by Augustus 
A. Eshner, M.D , Professor of Clinical 
Medicine in the Philadelphia Polyclinic. 

FRIEDRICH — Rhinology, La= 
ryngology, and Otology in 
their Relations to General 
Medicine. 

By Dr. E. P. Friedrich, of the Univer- 
sity of Leipsig. 

LEVY AND KLEMPERER — 
The Elements of Clinical Bac= 
teriology. 

By Dr. Ernst Levy, Professor in the 
University of Strassburg, and Dr. Felix 
Klemperer, Privat-Docent in the Univer- 
sity of Strassburg. Translated and edited 
by Augustus A. Eshner, M.D., Professor 
of Clinical Medicine in the Philadelphia Poly- 



McFARLAND— A Text=Book of 
Pathology. 

By Joseph McFarland, M.D., Professor 
of Pathology and Bacteriology, Medico-Chi- 
rurgical College, Philadelphia. 

OQDEN — Clinical Examination 
of the Urine. 

By J. Bergen Ogden, M.D., Assistant in 
Chemistry, Harvard Medical School. 

PYLE— A Manual of Personal 
Hygiene. 

Edited by Walter L. Pyle, M.D., Assis- 
tantSurgeon to Wills' Eye Hospital, Philada. 

SCUDDER— The Treatment of 
Fractures. 

By Charles L. Scudder, M.D., Assistant 
in Clinical and Operative Surgery, Harvard 
University. 

SENN— Practical Surgery. 

By Nicholas Senn, M.D. , Ph.D., LL.D., 

Professor of the Practice of Surgery and of 
Clinical Surgery, Rush Medical College, Chi- 
cago. Octavo volume of about 800 pages, 
profusely illustrated. 

The Pathology and* Treatment 
of Tumors. 

By Nicholas Senn, M.D., Ph.D., LL.D., 

Professor of the Practice of Surgery and of 
Clinical Surgery, Rush Medical College, Chi- 
cago. A New and Thoroughly Revised Edi- 
tion in preparation. 

STENGEL AND WHITE — The 
Blood in its Clinical and Patho- 
logical Relations. 

By Alfred Stengel, M.D., Professor of 
Clinical Medicine, University of Pennsyl- 
vania; and C. Y. White, M.D., Instruc- 
tor in Clinical Medicine, University of Penn- 
sylvania. 

STEVENS— The Physical Diag= 
nosis of Diseases of the Chest. 

By A. A. Stevens, A.M., M.D., Lecturer 
on Terminology, and Instructor in Physical 
Diagnosis, University of Pennsylvania. 

STONE Y — Surgical Technique 
for Nurses. 

By Emily A. M. Stoney, late Superin- 
tendent of the Training Schools for Nurses, 
Carney Hospital, South Boston, Mass. 



SAUNDERS' 
MEDICAL HAND-ATLASES. 

The series of books included under this title are authorized translations 
into English of the world-famous 

Lehmann Medicinische Handatlanten, 

which for scientific accuracy, pictorial beauty, compactness, and 
cheapness surpass any similar volumes ever published. 

Each volume contains from 50 to 100 colored plates, besides numer- 
ous illustrations in the text. The colored plates have been executed by the 
most skilful German lithographers, in some cases more than twenty im- 
pressions being required to obtain the desired result. Each plate is accom- 
panied by a full and appropriate description, and each book contains a con- 
densed but adequate outline of the subject to which it is devoted. 

One of the most valuable features of these atlases is that they offer a 
ready and satisfactory substitute for clinical observation. Such ob- 
servation, of course, is available only to the residents in large medical centers; 
and even then the requisite variety is seen only after long years of routine 
hospital work. To those unable to attend important clinics these books 
will be absolutely indispensable, as presenting in a complete and con- 
venient form the most accurate reproductions of clinical work, interpreted 
by the most competent of clinical teachers. 

While appreciating the value of such colored plates, the profession has 
heretofore been practically debarred from purchasing similar works because 
of their extremely high price, made necessary by a limited sale and an 
enormous expense of production. Now, however, by reason of their pro- 
jected universal translation and reproduction, affording international dis- 
tribution, the publishers have been enabled to secure for these atlases the 
best artistic and professional talent, to produce them in the most 
elegant style, and yet to offer them at a price heretofore unapproached 
in cheapness. The great success of the undertaking is demonstrated 
by the fact that the volumes have already appeared in thirteen different 
languages — German, English, French, Italian, Russian, Spanish, Dutch, 
Japanese, Danish, Swedish, Roumanian, Bohemian, and Hungarian. 

The same careful and competent editorial supervision has been 
secured in the English edition as in the originals. The translations have 
been edited by the leading American specialists in the different sub- 
jects. The volumes are of a uniform and convenient size (5 x 7^ inches), 
and are substantially bound in cloth. 

(For List of Books, Prices, etc. see next page.) 

Pamphlet containing specimens of the Colored Plates 

sent free on application. 



VOLUMES rfaw READY. 

Atlas and Epitome of Internal Medicine and Clinical Diagnosis. 

By Dr. Chr. Jakob, of Erlangen. Edited by Augustus A. Eshner, M.D., 
Professor of Clinical Medicine in the Philadelphia Polyclinic. With 68 
colored plates, 64 text-illustrations, and 259 pages of text. Cloth, #3.00 
net 

Atlas of Legal Medicine. By Dr. E. von Hofmann, of Vienna. Ed- 
ited by Frederick Peterson, Ml D., Chief of Clinic, Nervous Depart- 
ment, College of Physicians and Surgeons, New York. With 120 colored 
figures on 56 plates and 193 half-tone illustrations. Cloth, $3.50 net. 

Atlas and Epitome of Diseases of the Larynx. By Dr. L. Grun 
wald, of Munich. Edited by Charles P. Grayson, M. D., Physician- 
in-Charge, Throat and Nose Department, Hospital of the University of 
Pennsylvania. With 107 colored figures on 44 plates, 25 text-illustrations, 
and 103 pages of text. Cloth, $2.50 net. 

Atlas and Epitome of Operative Surgery. By Dr. O Zuckerkandl, 
of Vienna. Edited by J. Chalmers DaCosta, M. D., Clinical Professor 
of Surgery, Jefferson Medical College, Philadelphia. With 24 colored 
plates, 217 illustrations, and, 395 pages of text. Cloth, $3.00 net. 

Atlas and Epitome of Syphilis and the Venereal Diseases. By 

Prof. Dr. Franz Mracek, of Vienna. Edited by L. Bolton Bangs, 
M. D., Professor of Genito-Urinary Surgery, University and Bellevue Hos- 
pital Medical College, New York. With 71 colored plates, 66 text-illus- 
trations, and '122 pages of text. Cloth, $3.50 net. 

Atlas and Epitome of External Diseases of the Eye. By Dr. O. 

Haab, of Zurich. Edited by G. E. de Schweinitz, M. D., Professor of 
Ophthalmology, Jefferson Medical College, Philadelphia. With 76 colored 
illustrations on 40 plates and 228 pages of text. Cloth, $3.00 net. 

Atlas and Epitome of Skin Diseases. By Prof. Dr. Franz Mracek, 
of Vienna. Edited by Henry W. Stelwagon, M. D., Clinical Professor 
of Dermatology, Jefferson Medical College, Philadelphia. With 63 colored 
plates, 39 illustrations, and 200 pages of text. Cloth, $3.50 net. 

Atlas and Epitome of Special Pathological Histology. By Dr. H. 

Durck, of Munich. Edited by Ludvig Hektoen, M. D., Professor of 
Pathology, Rush Medical College, Chicago. Two volumes, with about 
120 colored plates, numerous text-illustrations, and copious text. 

Atlas and Epitome of Diseases Caused by Accidents. By Dr. Ed. 

Golebiewski, of Berlin. Translated and edited with additions by PeArce 
Bailey, M. D., Attending Physician to the Department of Corrections and' 
to the Almshouse and Incurable Hospital, New York. With 40 colored 
plates, 143 text-illustrations, and 600 pages of text. 

IN PREPARATION. 

Atlas of General Pathological Histology. Atlas of Operative Gynecology. 

Atlas of Orthopedic Surgery. Atlas of Psychiatry. 

Atlas of General Surgery. Atlas of Diseases of the Ear. 



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